Vo - Pob - Ab Labor (Passenger)
Vo - Pob - Ab Labor (Passenger)
Vo - Pob - Ab Labor (Passenger)
FACE PRESENTAION
• NECK is hyperextended, occiput is in contact with the fetal back
and the chin (mentum) is
presenting
• Fetal face may present with the • With the chin anterior, internal rotation of the face brings the chin
chin (mentum) anteriorly or under the symphysis pubis
posteriorly, relative to the
maternal symphysis pubis
• The occiput is the longer end of
the head level
• The chin is directly posterior
• Vaginal delivery is impossible
unless the chin rotates anteriorly
valortiguero 1 of 5
PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
• Fetal head between the orbital ridge ▪ contracted maternal pelvis
and anterior fontanel presents at the • Diagnosis → recognized by inspection alone
pelvic inlet ▪ Abdominal examination
• Fetal head occupies a position o Abdomen is unusually wide, whereas the uterine fundus
midway between full flexion (occiput) extends to only slightly above extends only slightly above
and extension (mentum or face) o No fetal pole is detected in the fundus, ballotable head is
• Engagement of fetal head and found in one iliac fossa and the breech in the other
delivery will not occur unless the o Back up (anterior) → a hard resistance plane extends
head is small or pelvis is unusually across the front of the abdomen
large o back down (posterior) → irregular nodulations
• The attitude of the head in brow representing the small parts are felt through the
presentation: → partially extended abdominal
▪ Face presentation → Fully ▪ Vaginal examination
extended o early stages of labor → the side of the thorax or the
▪ Occiput presentation → Fully flexed "gridiron" feel of the ribs
▪ Cinciput → partially flexed o Advanced labor → the scapula and clavicle are palpated
• Causes and etiology are the same as of the face presentation
• Unstable → may convert to occiput or face
• Management → same as face presentation
• Diagnosis
▪ Abdominal palpation → when both the occiput and chin
can be palpated easily
▪ Vaginal examination → palpation of the frontal sutures,
large anterior fontanel, orbital ridges, eyes, and root of the
nose
MECHANISM OF LABOR
• Very small fetus and a large pelvis
▪ Labor is generally easy → vaginal delivery is favorable
• Larger fetus
▪ Usually difficult, because engagement is impossible until
there is marked molding that shortens the occipitomental
• Diameter or, more commonly, until there is either flexion to an
occiput presentation or extension to a face presentation
• Persistent Brow
▪ vaginal delivery is difficult and management is same as
difficult and management is same as
TRANSVERSE LIE
• Note: Palpation in transverse lie, right acromiodorsoanterior
ETIOLOGY AND DIAGNOSIS position. A. First maneuver. B. Second maneuver. C. Third
• The fetus' long axis lies approximately perpendicular to that of the maneuver. D. Fourth maneuver
mother
• The shoulder is usually positioned over the pelvic inlet MECHANISM OF LABOR
• The head → occupies one iliac fossa, and the breech the other • Spontaneous delivery of a fully developed newborn is impossible
• Shoulder presentation with a persistent transverse lie
▪ The side of the mother on which the acromion rests • Rupture of the membranes → the fetal shoulder is forced into the
determine the designation of the position as right or left pelvis corresponding arm frequently prolapses shoulder is arrested
acromial by the margins of the pelvic inlet
▪ The back may be directed anteriorly or posteriorly and also • Margins of the pelvic inlet (head in one iliac fossa and the breech
superiorly or inferiorly in the other)
▪ Shoulder impacted in the upper pelvis
▪ Uterus contracts vigorously → pathologic retraction ring
(neglected transverse lie) → rupture of the uterus
• Bandl ring → extreme form – pathologic
▪ Uterine contraction ring rises increasingly higher and
becomes more marked
valortiguero 2 of 5
PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
• CONDUPLICATO CORPORE • Perinatal loss → increased as a result of preterm delivery,
▪ The fetus, which is doubled upon itself in a position prolapsed cord, and traumatic obstetrical procedures
▪ Fetus compressed w/ head forced into the abdomen → • In most cases, the prolapsed part left alone, because most often it
portion of thoracic wall below the shoulder, most dependent will not interfere with labor
part, appears at the vulva, head & thorax → pelvic cavity → • Prolapsed arm alongside the head-
expelled • Ascertain whether the arm retracts out of the way with descent of
▪ Fetus become ball possible to be delivered vaginally the presenting part → fails to retract → prolapsed arm pushed
gently upward, and the head downward by fundal pressure
MANAGEMENT
• In general, active labor in transverse lie is an indication for PERSISTENT OCCIPUT POSTERIOR POSITION
cesarean delivery • 2-10 % of deliveries → adequate antero-posterior diameter +
• Because neither the feet nor the head of the fetus occupies the narrow midpelvis = Anthropoid pelvis (oval Antero posteriorly)
lower uterine segment • Most common cause of Prolonged 2nd stage of Labor
• Low transverse incision may lead to difficult fetal extraction → • Transverse narrowing of the midpelvis is undoubtedly a contributing
vertical hysterotomy incision is indicated factor
▪ With dorsoposterior or back up position – one or both feet • Usually undergo spontaneous anterior rotation followed by
can be grasped through a low transverse incision and uncomplicated rotation followed by uncomplicated → vaginal
delivered by breech extraction delivery
• Before labor or early in labor → with the membranes intact → • Risk Factors:
external cephalic version (ECV) is worthwhile ▪ Failure of Internal Rotation
▪ Candidate selection and ECV technique mirror those for the ▪ Epidural analgesic
breech fetus ▪ Nulliparity
▪ ECV success rates are high and exceed those for breech ▪ Greater fetal weight
fetuses ▪ Prior Occiput posterior position delivery
• Morbidity associated with POP:
OBLIQUE LIE ▪ Prolonged second stage of labor
• Called an unstable lie ▪ Increased CS delivery and operative vaginal delivery
• When the long axis forms an acute angle ▪ Increased blood loss → (vaginal delivery) – due to the
• Usually only transitory, because either a longitudinal or transverse laceration
lie commonly results when labor supervenes ▪ Higher order vaginal lacerations (3rd and 4th degree
lacerations)
Additional:
COMPOUND PRESENTATION
• An extremity prolapses alongside the presenting part or with both
presenting in the pelvis simultaneously
valortiguero 3 of 5
PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
COMPLICATION WITH SHOULDER DYSTOCIA
• 0.6 1.4% incidence
• Head to body delivery time
▪ Normal birth → 24 second
▪ Shoulder dystocia → > 60 seconds or 1 min
• Fetal shoulder become wedged behind symphysis pubis and fail to
deliver with downward traction and pushing
• EMERGENCY → because the umbilical is compressed within the
birth canal
• neonates experiencing shoulder dystocia had significantly greater
shoulder-to-head and chest-to-head disproportions compared with
those of equally macrosomic newborns delivered without dystocia
▪ True of babies of diabetic Mothers → they have wider
shoulder span
valortiguero 4 of 5
PATHOLOGIC OBSTETRICS
ABNORMAL LABOR (PASSENGER)
• Deliberate fracture of the clavicle
▪ Pressing the anterior clavicle against the ramus of the pubis
to free the shoulder impaction
• Hibbard maneuver
▪ Pressure is applied to the fetal jaw and neck in the direction
of the maternal rectum, with strong fundal pressure applied
by an assistant as the anterior shoulder is freed
• Zavanelli maneuver
▪ Cephalic replacement into the pelvis and then cesarean
delivery
• Cleidotomy
▪ Cutting the clavicle with scissors or other sharp instruments
▪ Usually used for a dead fetus
• Symphysiotomy
Note:
If the above maneuvers fail
• Delivery of posterior arm
• Woodscrew
• Rubin's manever
• If it fails:
▪ Cleidotomy
▪ Zavanelli
▪ Symphysiotomy
END
valortiguero 5 of 5