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PASSENGER FACE PRESENTATION the head is hyperextended , occiput is in contact with the fetal back and the chin

n (mentum) is presenting fetal face may present with the chin (mentum) anteriorly or posteriorly, relative to the maternal symphysis pubis The occiput is the longer end of the head lever. The chin is directly posterior. Vaginal delivery is impossible unless the chin rotates anteriorly Diagnosis Vaginal examination palpation of the distinctive facial features of the and nose, the malar bones, and particularly the orbital

mouth ridges

Radiographic examination demonstration of the hyperextended head with the facial bones at or below the pelvic inlet Etiology Marked enlargement of the neck or coils of cord about the neck may cause extension Anencephalic fetuses Contracted pelvis Very large fetus Multiparous women Mechanism of Labor Face presentations rarely are observed above the pelvic inlet The brow generally presents, converted into a face presentation after further extension of the head during descent Mechanism of labor consists of the following cardinal movements: Descent - brought about by the same factors as in cephalic presentations internal rotation - the objective is to bring the chin under the symphysis pubis

- results from the same factors as in vertex presentations flexion accessory movements of extension and external rotation - results from the relation of the fetal body to the deflected head

Mechanism of labor for right mentoposterior position with subsequent rotation of the mentum anteriorly and delivery Management In the absence of a contracted pelvis, and with effective labor, successful vaginal delivery usually will follow Cesarean delivery Because face presentations among term-size fetuses are more common when there is some degree of pelvic inlet contraction, cesarean delivery frequently is indicated.

BROW PRESENTATION Rarest presentation because it is unstable and often converts to a face or occiput presentation The portion of the fetal head between the orbital ridge and anterior fontanel presents at the pelvic inlet The fetal head thus occupies a position midway between full flexion (occiput) and extension (mentum or face) Only transient prognosis depends on the ultimate presenting part Causes are the same as of the face presentation Management is the same as those for a 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 with a 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 TRANSVERSE LIE the long axis of the fetus is approximately perpendicular to that of the mother referred to as shoulder or acromnion presentation the shoulder is usually on the pelvic inlet, with the head lying on one iliac fossa and the breech in another Diagnosis Abdominal examination abdomen is unusually wide, whereas the uterine fundus extends to only slightly above the umbilicus. no fetal pole is detected in the fundus, ballottable head is found in one iliac fossa and the breech in the other back up (anterior) - a hard resistance plane extends across the front of the abdomen back down (posterior)- irregular nodulations representing the small parts are felt through the abdominal wall. Diagnosis Vaginal examination early stages of labor: the side of the thorax or the "gridiron" feel of the ribs Advanced labor: the scapula and clavicle are palpated

Palpation in transverse lie, right acromidorsoanterior position. A. First maneuver. B. Second maneuver. C. Third maneuver. D. Fourth maneuver. Etiology Abdominal wall relaxation from high parity. Preterm fetus. Placenta previa. Abnormal uterine anatomy. Excessive amnionic fluid. Contracted pelvis. Mechanism of Labor Spontaneous delivery of a fully developed newborn is impossible with a persistent transverse lie rupture of the membranes the fetal shoulder is forced into the pelvis corresponding arm frequently prolapses shoulder is arrested by the margins of the pelvic inlet ( head in one iliac fossa and the breech in the other) impacted shoulder neglected transverse lie uterine rupture

Neglected shoulder presentation. A thick muscular band forming a pathological retraction ring has developed just above the thin lower uterine segment. The force generated during a

uterine contraction is directed centripetally at and above the level of the pathological retraction ring. This serves to stretch further and possibly to rupture the thin lower segment below the retraction ring. (P.R.R. = pathological retraction ring.) If the fetus is smallusually less than 800 gand the pelvis is large, spontaneous delivery is possible despite persistence of the abnormal lie Management In general, the onset of active labor in a woman with a transverse lie is an indication for cesarean delivery Because neither the feet nor the head of the fetus occupies the lower uterine segment, a low transverse incision into the uterus may lead to difficulty in extraction of a fetus entrapped in the body of the uterus above the level of incision. Therefore, a vertical incision is likely to be indicated OBLIQUE LIE called an unstable lie when the long axis forms an acute angle usually only transitory, because either a longitudinal or transverse lie commonly results when labor supervenes COMPOUND PRESENTATION an extremity prolapses alongside the presenting part, with both presenting in the pelvis simultaneously The left hand is lying in front of the vertex. With further labor, the hand and arm may retract from the birth canal and the head may then descend normally. Causes conditions that prevent complete occlusion of the pelvic inlet by the fetal head, including preterm birth Prognosis and Management Perinatal loss is increased as a result of concomitant preterm delivery, prolapsed cord, and traumatic obstetrical procedures In most cases, the prolapsed part should be left alone, because most often it will not interfere with labor Prolapsed arm alongside the head close observation to ascertain whether the arm retracts out of the way with descent of the presenting part, if it fails to retract and if it appears to

prevent descent of the head, the prolapsed arm should be pushed gently upward and the head simultaneously downward by fundal pressure vaginal delivery PERSISTENT OCCIPUT POSTERIOR POSITION Transverse narrowing of the midpelvis is undoubtedly a contributing factor Usually undergo spontaneous anterior rotation followed by uncomplicated delivery The possibilities for vaginal delivery are: Spontaneous delivery Forceps delivery with the occiput directly posterior Manual rotation to the anterior position followed by spontaneous or forceps delivery Forceps rotation of the occiput to the anterior position and delivery PERSISTENT OCCIPUT TRANSVERSE POSITION Most likely a transitory one because the occiput tends toward the anterior position in the absence of a pelvic architecture abnormality Spontaneous anterior rotation usually is completed rapidly, thus allowing the choice of spontaneous delivery or delivery with outlet forceps. If rotation ceases because of poor expulsive forces and pelvic contractures are absent, vaginal delivery usually can be accomplished The occiput may be manually rotated anteriorly or posteriorly and forceps delivery performed from either the anterior or posterior position Delivery Application of Kielland forceps to the fetal head to rotate the occiput to the anterior position, and then deliver the head either with the same forceps or with Simpson or Tucker McLane forceps Oxytocin may be infused and closely monitored With the platypelloid (anteroposteriorly flattened) and the android (heart-shaped) pelves, there may not be adequate room for rotation of the occiput to either the anterior or the posterior position.

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