1. MAL PRESENTATION, MAL POSITION & CORD PROLAPSE TRISHA KELLY & SARAH McLEOD TRAINING & PRACTICE DEVELOPMENT CO-ORDINATORS, MATERNITY SERVICES, NHS HIGHLAND

2. AIMS & OBJECTIVES LOOK AT TYPES OF MAL PRESENTATION & POSITION (MAIN FOCUS ON BREECH) HOW TO MANAGE IN DIFFERENT PRACTICE ENVIRONMENTS LOOK AT SOME ALTERNATIVE THERAPIES CONSOLIDATE WITH ‘HANDS ON’ PRACTICE

3. OCCIPITOPOSTERIOR POSITION (OP) INCIDENCE IS AROUND 10% 5% DELIVER IN OP POSITION PREVIOUS OP LABOUR – MORE LIKELY TO HAVE A REPEAT ADVISE MUM OF OPTIMAL FETAL POSITIONING MOBILISATION IN LABOUR IMPORTANT LEAVE MEMBRANES INTACT HOPEFULLY ROTATION WILL HAPPEN IN LABOUR FOLLOWED BY SPONTANEOUS DELIVERY. IF NOT……….

4. OP CONTINUED… MANUAL ROTATION ROTATION USING VENTOUSE CUP ROTATIONAL FORCEPS CAESAREAN SECTION

5. MANUAL ROTATION OF LOP

6. COMPLETE ROTATION

7. FACE PRESENTATION INCIDENCE IS ABOUT 1:600 CAN BE CONFUSED WITH BREECH ON VAGINAL EXAM – FEEL FOR MOUTH & MALAR PROMINANCES (TRIANGULAR SHAPE) CHIN MUST BE ANTERIOR TO ALLOW VAGINAL DELIVERY HEAD DELIVERS BY FLEXION FACE CAN BE VERY DISTORTED

8. FACE PRESENTATION

9. BROW PRESENTATION INCIDENCE IS ABOUT 1:700 ASSOCIATED WITH CONTRACTED PELVIS AND OP POSITION BIGGEST PRESENTING DIAMETER MENTOVERTICAL (13.5CM) & EXCEEDS ALL DIAMETERS IN THE MATERNAL PELVIS PRESENTING PART USUALLY HIGH ON VE (CARE NOT TO RUPTURE MEMBRANES) MAY CONVERT TO A FACE WILL DELIVER VAGINALLY, NEEDS TO ROTATE TO OP USUALLY CAESAREAN SECTION IS INDICATED

10. BROW PRESENTATION

11. TRANSVERSE OR OBLIQUE LIE INCIDENCE IS ABOUT 1:500 ASSOCIATED WITH LAX UTERINE MUSCLES OR UTERINE ANOMALIES PRESENTING PART USUALLY SHOULDER & THERE IS NO MECHANISM FOR VAGINAL DELIVERY RISK OF CORD PROLAPSE HIGH TRANSFER PRIOR TO LABOUR, IF IN LABOUR EMERGENCY TRANSFER GOOD RISK MANAGEMENT VITAL HERE

12. NOT GOOD!

13. BREECH PRESENTATION 3-4% AT TERM LOOK FOR TUBEROSITIES & ANUS IN A STRAIGHT LINE ON VE (LABOUR) USUALLY FRANK BUT CAN BE COMPLETE, FOOTLING OR KNEELING CAESAREAN SECTION NORM FOR ‘SAFE’ DELIVERY TERM BREECH TRIAL (HANNAH ET AL 2000) ‘3 TIMES LESS LIKELY TO DIE OR SUFFER SERIOUS MORBIDITY THAN MEDICALLY MANAGED VAGINAL DELIVERIES’

14. TYPES OF BREECHES: EXTENDED, COMPLETE & FOOTLING

15. BREECH – EXTERNAL CEPHALIC VERSION SHOULD BE OFFERED TO ALL WOMEN WITH AN UNCOMPLICATED BREECH AT TERM MUST BE DONE IN A CONTROLLED ENVIRONMENT EFFECTIVE TOCOLYTIC DRUG MUST BE USED OPERATOR EXPERIENCED & COMPETENT

16. BREECH – ALTERNATIVE THERAPIES POSITIONING - MATERNAL ACUPUNCTURE USING MOXIBUSTION CHINESE HERBAL MEDICINE – HERB USED ARTEMISIA VULGARIS MADE INTO A STICK (MOXA) BURNT AT THE LATERAL SIDE OF THE LITTLE TOE ACUPUNCTURE POINT ‘BLADDER 67’ CAN BE DONE TWICE PER DAY UNTIL BABE TURNS USUALLY WHEN THE UTERUS HAS MAXIMUM LIQUOR AROUND 34 WEEKS

17. BREECH – VAGINAL DELIVERY LOST SKILLS ‘HANDS OFF’! ‘LITHOTOMY’ POSTION ADAPT IF AT HOME OR STANDING, SQUATTING, KNEELING SHOULD ALLOW 5 MINS FOR LEGS, BODY, ARMS & HEAD – PATIENCE!! MAY NEED TO ASSIST LIMBS ESP. ARMS CONTROLLED DELIVERY OF HEAD – MODIFIED MAURICEAU-SMELLIE-VIET (MSV)

18. BREECH – EXTENDED LEG

19. BREECH – EXTENED ARM (LOVSET MANEOUVRE)

20. BREECH – MAURICEAU- SMELLIE-VEIT

21. BREECH MSV - CONT

23. BREECH – MSV CONTINUED

24. SUMMARY… GOOD RISK MANAGEMENT ADVISE MUM ON OPTIMAL FETAL POSITIONING (OP) HOME/CMU BIRTH – ULTRA SOUND TO CONFIRM PRESENTATION ‘FIRE DRILLS’ FOR VAGINAL BREECH ESPECIALLY

25. Cord Prolapse

26. Associated Risk Factors Multiparity Malpresentation Multiple pregnancy Prematurity Polyhydramnios High presenting part Artificial rupture of membranes when presenting part is high

27. Objectives Identify risk factors for cord prolapse Diagnosis of cord prolapse Identify management options

28. Definition and Incidence Cord Presentation The umbilical cord lies below or alongside the presenting part with membranes intact Cord Prolapse The cord lies below or alongside the presenting part in the presence of ruptured membranes Incidence: 0.2 – 0.5% of all births

29. CORD PROLAPSE

30. Diagnosis Cord visible at vulva Cord felt on vaginal examination Abnormal fetal heart rate – variable decelerations or bradycardia

31. Management Get help - if cord pulsating, fetus is alive Explain to woman and partner emergency measures that are required Diagnose stage of labour by vaginal examination (keep cord handling to a minimum) Relieve pressure on cord by elevating the presenting part Alter maternal position – ‘Knee-chest’ or ‘Exaggerated Sim’s’ to elevate buttocks Emergency transfer if in community – consider safety

32. MANAGEMENT CON’T FILL URINARY BLADDER 500 MLS NORMAL SALINE – CLAMP BUYS TIME MAY INHIBIT UTERINE CONTRACTIONS

33. SUMMARY Call for help – team work vital Explanation of emergency situation to woman and partner Elevate presenting part off cord Knee-chest position or elevate buttocks Keep cord in vagina (minimal handling) Expedite delivery ‘Fire Drills’