1. Dr. Nadia Saddam AL.Assady
Mal position By
Dr. Nadia Saddam AL.Assady
C.A.B.O.G

2. Mal position:
it refers to when the fetal vertex presents to the maternal pelvis in position other than flexed in occipito- anterior position. Mal position include occipito- transverse & occipito- posterior position & may involve some degree of asynclitism (side way tilt of the head).
Etiology:
Majority of OP position (68%) confirmed toward the end of lobar & minority of OP position (32%) began lobar as OP position.

3. 1- maternal pelvis shape is thought to be the major cause for OP position like android & arthropoid position the quality of uterine contractions play a significant part in determining the position & attitude of the fetal head the tone of the pelvic floor is also relevant so use of regional anesthesia has implicated as mechanism for malposition but no evidence bases for that.

4. Incidence:
During the antepartum period the OP position exist in around (10%). Once lobar starts the incidence increase to (20-25%) if the fetal back is on the maternal left , the OP position is much less common than when the back is on the maternal right. It is more common in cases of membrane rupture before the onset of lobar. Between (20-30%) of those that start lobar in an OP position remain in that position to the end of lobar indicating that ( 65-80%) undergoes spontaneous rotation during lobar as few as (1-5%) are delivered in OP position.

8. Diagnosis:
1-the abdomen is flat with a dip between the head & the trunk may be evident the fetal back is difficult to identify on palpation but the shoulder is felt toward the flank with the limbs often obvious to palpation over the abdomen the fetal heart is heard maximally in the flanks to which the back is directed during lobar , the anterior fontanel is easier to reach, although caput succedaneum may make it more difficult. 5-palpation of more the anterior of the two ear can be helpful. 6-diagnosis of deep transverse arrest is not difficult unless caput succedaneum or anterior or posterior asynclitism is marked so again palpation of fetal ear is helpful.

9. management:
antenatal:
it is of little benefit from trying to alter an OP position diagnosed in the antenatal period because majority of cases correct themselves when lobar started but they should give some advice that there may be rupture membrane, the lobar may be uncomfortable & prolonged, they may require assisted vaginal delivery or may require delivery by C/S.

10. intrapartum:
when the diagnosis of malposition is made early in lobar so information about the fetal position including the amount of head palpable per abdomen, the degree of deflexion & asynclitism, the amount of molding & caput formation, the level of presenting part in relation to the iscial spine & maternal pelvis size & shape.
Fetal wellbeing including fetal heart rate pattern & the color of liquor should be noticed.

11. Option of management include:
1-no specific action if acceptable progress is being made.
2-provide oxytocin augmentation if uterine contraction are in coordinate, infrequent or of poor quality abandoning lobar in favor of C/S encourging the patient to lie on the same side as the fetal back.
5-once the 2nd stage of lobar has been reached so either:
a*spontaneous delivery in the OP position may occur as face to pubis.

12. b*spontaneous rotation may still occur with spontaneous delivery as occipito- anterior c*delivery may be delayed by persistence OP position or the evolution of deep transverse arrest.
It has been suggested that vaginal manipulation to rotate the fetus to an OA position should b avoided if there is fetal distress with resort instead to delivery by C/S or use instrumental delivery to rotate to OA position & delivered.

13. Umbilical cord prolapse:
What is the umbilical cord?
The umbilical cord is flexible, tube like structure that during pregnancy connect the fetus to mother. The umbilical cord is the baby, s life line to the mother . it transport nutrients to the baby & also carries away the baby, s waste products. Its made up of 3 blood vessels ( 2 arteries & 1 vein).

14. Definition of umbilical cord prolapse:
Is defined as descent of a loop of umbilical cord into the lower uterine segment, where it may lie adjacent to the presenting part(occult cord prolapse) or below the presenting part(overt cord prolapse).
Cord prolapse:
Where the umbilical cord lies in front of or beside the presenting part in the presence of ruptured membrane.
Cord presentation:
Where the umbilical cord lies in front of the presenting part in the presence of intact membrane.

15. In occult prolapse, the umbilical cord cannot be palpated during pelvic examination, where as in funic presentation the cord can be palpated in front of the presenting part with intact membrane, where as in overt type, the membrane are rupture & the cord is displaced into the vagina or introitus.
incidence:
the incidence of overt umbilical cord prolapse is( %) of births a-cephalic ( %). b-frank breech (0.5%) c-complete breech (5%). d-footling breech (15%) e-transverse lie (20%). f-multiple pregnancy (4%).

16. What are the consequences of umbilical cord prolapse:
Prolapse of umbilical cord below the presenting part lead to intermittent compression between the presenting part & the genital canal lead to fetal circulation compression ( depending on intensity & duration) lead to fetal hypoxia , brain damage & death.
In overt type spasm of the cord vessels may occur when exposed to cold or manipulation.

17. Risk factors:
Fetal factors: prematurity, polyhydramnious, multiple pregnancy, mal presentation, anencephaly, premature ruptured membrane & long cord.
Maternal factors: pelvic tumor, placenta praevia, CPD.
Obstetric intervention: ARM, intrauterine catheter pressure, ECV.
Clinical findings:
The mother cannot feel if the umbilical cord is prolapsed .A-overt prolapse: visualizing the cord protruding from the introits or by palpating loops of cord in vaginal canal B-funic presentation: loops of cord may be palpated through the membrane.

18. C-occult prolapse: variable heart deceleration, fetal brady cardia
C-occult prolapse: variable heart deceleration, fetal brady cardia D-fetus: may be in good condition or variable deceleration during contractions. Persistent, severe, variable deceleration & Brady cardia lead to development of hypoxia, metabolic acidosis, fetal damage & death. Fetal activity deceases & eventually ceases, meconium staining liquor may be noticed.
Diagnosis:
1-vaginal examination if cord is prolapsed one should check if it is pulsating or not.
2-U/S: this is done to confirm a fetal heart. It may diagnose cord presentation. Color Doppler sonography can diagnose cord presentation.

19. Complications:
a-maternal: most of these patients deliver by C/S with all its anesthetic , hemorrhagic & operative complications. Instrumental delivery may be used which may cause cervical, vaginal & perineum lacerations.
b-neonatal: the neonate at delivery may be hypoxic, acidotic or dead. The prognosis depends on degree & duration of umbilical cord compression & neonatal resuscitation. If the baby delivers within less than (5 minutes) the prognosis is good. Gestational age & trauma also determine neonatal outcome.

20. Prevention:
1-patients at high risk for cord prolapse should be carefully managed in lobar with continuous fetal heart monitoring patients with mal presentation & non engaged head should evaluated by U/S to check fetal lie & cord position within uterine cavity at the onset of lobar ARM should be avoided until the presenting part is well applied to the cervix careful pelvic examination should be done at the time of spontaneous rupture of membrane to rule out cord prolapse

21. 5-if amniotomy is required in patient with non-engaged head or poly hydramnios , needling of the membrane should be done with slow release of the amniotic fluid until the presenting part settles against the cervix.
Management :
a-overt cord prolapse: an immediate pelvic examination should be performed to check cervical effacement & dilatation, station of the presenting part
& the strength & the frequency of pulsation in the cord.
2-if the fetus is viable with still not fully dilated cervix , the patient should be placed in knee-chest position

22. & the examiner should apply continuous up word pressure against the presenting part thus left the fetus away from the cord until C/S is done Oxygen should be given by mask & oxytocin should be stopped & rapid i.v fluid should be given. Give salbutamole (0.5 mg iv slowly) over 2 minutes to reduce contractions
3-bladder filling by catheter with 500 mg normal saline may be applied until C/S is to be done, bladder filling will elevate the presenting part & also may decrease or inhibit uterine contractions, release catheter clumping is to be done before opening peritoneal cavity.

23. 4-do not replace the protrude cord into the uterus, the cord should be moistened with sterilized gauze soaked in warm saline.
5-in the absence of fetal heart, urgent U/S should be performed for fetal viability if the cervix is fully dilated with live fetus, vacuum extractor may be applied.
b-occult cord prolapse: if variable deceleration is detected, pelvic examination should be done to rule out occult cord prolapse.
2-if occult cord prolapse is suspected, put the patient in lateral Sim, s position or tredelenburg position, oxygen should be administered , if the fetal heart return to normal, lobar may allowed to continue.

24. 3-amnioinfusion may be performed by intrauterine pressure catheter to instill fluid within uterine cavity to decrease the incidence of variable deceleration if brady cardia or variable deceleration persists or recurs, a rapid C/S should be performed.
c-Funic presentation:
1-if patient at term with funic presentation, delivery by C/S should be performed.
2-if the fetus is preterm, the patient should be hospitalized at bed rest in Sim, s or Trendelenburg position with serial U/S examination to check out cord position, presentation & gestational age. Dexamethasone should be given for maturation of fetal lung.

25. d-route of delivery :
1-vaginal delivery is the goal in case of overt or occult prolapse if the cervix is fully dilated, no CPD& if the presenting part is lowdown. Vantose may be used, vaginal delivery is also the route of choice in case of immature or dead fetus.
2-no rule of internal podalic version.

26. Thank you