1. Malpresentaton and Breech presentation

2. Definitions Position The relationship of a defined area on the presenting part to the mother’s pelvis (Denominator) Presentation The part of the fetus occupying the lower segment The part of fetus felt on vaginal examination

3. Normal Presentation Normal Presentation; Bony Pelvis – Pelvic Brim –Pelvic cavity –Pelvic outlet

4. Vertex The area of the skull between the anterior and posterior fontanelles, and the parietal eminence Top of the skull Occiput Back of the fetal head behind the posterior fontanelle Sinciput That part of the fetal head in front of the anterior fontanelle.-forehead or brow

6. Malpresentation  Breech  Face  Brow  Shoulder  Cord  Compound

9. Consequences Presnting part, ill-fitting Uterine Contractions, poor Membranes, rupture early- cord prolapse Labour, difficult, long, obstructed Birth trauma Operative intervention

10. Mother, Fetus and neonate Increased perinatal mortality and morbidity Fetal malformation Intrauterine fetal death Cord proplase Birth trauma, Birth asphysixa Infection, fetus, neonate and mother Uterine rupture Thromboembolism in the mother

11. For Optimal Result Early diagnosis, Planned delivery Experienced staff Well equipped hospital Cross match 2 unit Adequate hydration Monitor in Labour Pain relief

12. Face Presentaion 1:300 Full extension of the head Presenting part: Face Denominator: Omentum/Chin Diameter; Subomento bregmatic 9.5cm Presentation, Mento anterior– Vaginal delivery Mento posterior- Ceasaeran section

13. Causes Anenecephaly Prematurity Multifetal pregnancy Polyhydramnious Neck tumours Sternomastoid spasm Multiparty

14. Diagnosis Abdominal Vaginal

15. Brow Presentation 1:800, 1:2000 deliveries The area between the orbital ridge and the anterior fontenalle Most unfavourable of all presentation Transient presentation; Full flexion—Occiput Full extension---Face

16. Dignosis and management Delivery??

17. Shoulder presentation  Causes Multiparty Prematurity Multiple pregnancy Polyhydrmanious congenital uterine anomly Contacted pelvis Pelvic tumour, placenta previae

18. Compound presentation Limb, limbs, umbilical cord alongside the presenting part; cephalic or breech

19. Umbilical cord presentation Umbilical cord, alongside or below the presenting part, membranes intact. Cord prolapse, the memebranes have ruptures

20. Breech presentation -Fetus presenting by the buttock/ feet/foot Types 30% at 30 weeks, 3% of all deliveries at term  Flexed Fetal buttock as well as fetal feet present to the pelvic inlet  Extended The buttock alone present to the pelvic inlet (Frank)  Fooling one or both feet presenting

22. Causes of breech presentation Prematurity Multiparity Multiple pregnancy Pelvic mass Placenta previae Fetal malformation

23. Risks Increased perinatal morbidity and mortality Due to; Prematurity Congenital abnormalities; hydrocephalus Cord prolapse Birth asphyxia Birth trauma ; intra-cranial haemorrhage

24. Diagnosis Abdominally, Palpation:  Soft irregular presenting part  Firm, round, ballottable head in the uterine fundus

25. Management No action until 37-38 weeks of gestation Reason??? Exclude fetal anomalies Placenta previae Multiple pregnancy Offer external cephalic version (ECV) Should not be attempted if there are risks Risks??? Prerequisites?? Drawbacks of ECV

26. Delivery Assisted Vaginal Breech delivery Elective Caesarean Section (CS) Emergency CS Selection for vaginal delivery Average fetal weight not more than 3.5kg Normal pregnancy No growth restriction Willing parents Experienced staff, Midwife, Obstet, neonatologist, anesthetist

27. Assisted vaginal breech delivery Close supervision Epidural analgesia Progress of labour Second stage of labour, can be dangerous Observe for delivery of the breech, Hands off oHelp is needed if the arms are extended above the head Lovset’s manoevour to deliver the shoulder oDelivery of head, forceps or head traction jaw flexion

28. Sutures The term applied to the junction between the bones of the fetal skull, the chief sutures are between the frontal bones( frontal) parietal bone( sagittal), parietal and frontal (coronal), parietal and occiput (Lmbdoid). Caput succedaneum Oedema from obliterated venous return and lymphatic drainage in the fetal scalp caused by pressure of the head against the rim of the cervix or birth canal not limited by suture. Collection between appenerouses and periostium. Cephalhaematoma A collection of blood beneath the periostium of a skull bone. Limited by sutures, appear after few hours of birth.

29. Definitions related to fetus Bregma; The large diamond shaped anterior fontanelle Fontanelles; Space at the junction of three or skull bones, covered by a membrane and skin. Can be felt by running a finger through 360 degrees to feel the sutures. Anterior Fontenalle Posterior Fontenalle Small and triangular space in the fetal skull situated in the posterior end of the sagittal sutures.

30. Attitude of fetus Relationship of fetal head and limbs to fetal trunk, usually flexion Lie of the fetus Relationship of the long axis of fetus to the long axis of the uterus, usually longitudinal lie, ( Transverse, oblique). Usually to the long axis of the mother. Position of the fetus The relationship of a defined area on the presenting part, called the denominator to the mother’s pelvis

31. Further readings www.patient.co.uk

32. The following statements about breech delivery are correct 1.Lovset’s manouver is employed to deliver the head. 2.Breech extraction is less hazardous than assisted beech delivery