Abnormalities of the

Passenger

Liu Yuling M.D.

Department Of Obstetrics & Gynecology
Renmin Hospital Wuhan University
Abnormalities of the Passenger

 Be known as fetal dystocia

 That is that are caused by abnormalities of
the fetus.
 Common fetal abnormalities leading to
dystocia include
 Excessive fetal size
 Malposition
 Congenital anomalies
 Multiple gestation
 Malposition and Malpresentation
 Vertex malpositions
 Occiput posterior
 Occiput transverse
 brow presentation
 Face presentation
 Abnormal fetal lie
 Breech presentation
 Compound presentation
 Fetal Macrosomia
 Fetal Malformation
Occiput posterior
occiput posterior position

 Itmay be normal in
early labor, with
about 10-20% of
fetuses in occiput
posterior position at
onset of labor.
 In 87% of cases,
the head rotates
to the occiput
anterior position
when it reaches
the pelvic floor
 Ifthe head does not rotate ( about 5-
10% of cases ), persistent occiput
anterior position may result in dystocia.
 Approximately two-thirds of cases of
occiput posterior presentation at delivery
occur through malrotation during the
active phase of labor.
Mechanism

 The mechanism of this fetopelvic

disproportion is partial deflexion of the
fetal head
 This partial deflexion increases the
diameter that must engage in the pelvis
Causative factors

A contracted pelvis
 Anthropoid pelvis
 Android pelvis

 Insufficient
uterine action
 Epidural anesthesia
 Oxytocin augmentation
Diagnosis

 Manual vaginal examination

 The diagnosis is generally
made by manual vaginal
examination of the orientation
of the fetal cephalic sutures.
 It may by confirmed by
palpating the configuration of
the fetal ear
Treatment

 Infusing of oxytocin
 Clinical pelvimetry should be attempted
 If no gross pelvic contraction is
documented and uterine contractions
are inadequate, cautious infusion of
oxytocin may be tried
The modes of delivery
 Depending on the clinical findings, the
following modes of delivery are available:
 Spontaneous vaginal delivery
 Outlet forceps delivery of a direct occipital posterior
presentation
 Manual rotation to the occipital anterior position,
followed by spontaneous or out forceps delivery
 Misfire rotation and extraction

 Vacuum extraction for rotation, extraction, or both

 Cesarean section
Occiput directly posterior. Low forceps (Simpson) delivery as an
occiput posterior. (O= occiput, S = symphysis.)
PERSISTENT OCCIPUIT POSTERIOR
POSITION
 Manual rotation
Manual rotation to the occipital anterior position
followed by spontaneous or out forceps delivery
Prognosis

 The infant
The prognosis of the infant is excellent
when macrosomia and gross fetopelvic
disproportion have been excluded, other
criteria for forceps delivery have been
met, and the operator is sufficiently
skilled
Maternal morbidity

 Maternal morbidity
It occurs more frequently in
occipital posterior deliveries
 Extension of episiotomies
 Higher rates of anal sphincter injury

 Other birth canal lacerations

Occiput transverse
Occiput transverse

 It(like occiput posterior) is frequently a

transient position, and in most labor the
fetal head spontaneously rotates to the
occiput anterior position
LOT(left occipito-transverse) ROT(right occipito-transverse)
Persistent Occiput transverse

It is frequently associated with

 Pelvic dystocia
 Platypelloidpelvis
 Android pelvis

 Uterine dystocia
 Diagnosis, management and prognosis
are similar to those of persistent occiput
posterior presentation
 When the fetal head engages but for
various reasons does not rotate
spontaneously in the midpelvis as in
normal labor, midpelvic transverse arrest
is diagnosed.
Deep transverse arrest

 Occasionally occurs at the inlet

 Molding and caput succedaneum
formation falsely indicating a lower
descent
 Cesarean section is required
Brow presentation
Brow Presentation

 Brow presentation usually is transient

fetal presentations with various degrees
of deflexion of the fetal head
 During the normal course of labor,
conversion to face or vertex presentation
generally occurs
 If no conversion takes place, dystocia is
likely
The attitude of fetuses’ head

occiput bregma brow

presentation presentation persentation

flex Not flex deflextion

Not extention
 12

9.5

13.5
•The anteroposterior diameter of the deflexed fetal head exceeds the average
9.5 cm of the suboccipitobrematic diameter in vertex presentation.
•The average value for the occipitofrontal diameter in the sinciput position is 12
cm for the occipitomental diameter in the brow position, 13.5 cm.
presentation The average value

vertex presentation suboccipitobrematic diameter 9.5 cm

sinciput position occipitofrontal diameter 12 cm

bregma presentation

brow position occipitomental diameter 13.5 cm

 Causative factors
Be associated with the same causative factors
as face presentation.
 Associated findings

In approximately 60% of cases, pelvic

contraction, prematurity, and grand multiparity
are associated findings.
 Diagnosis

The diagnosis is made by vaginal examination

Management

 Initial management is expectant

 Spontaneous conversion to vertex
presentation occur in more than one –
third of all brow presentations.
 Arrest patterns and uterine inertia are
common sequelae because pelvic
contraction is so often associated
with this presentation.
 Oxytocin is not recommended
 Continuous electronic fetal monitoring
is necessary
 Liberal use of cesarean section should
be made for delivery in cases
complicated by a poor outlook for labor
Prognosis

 Perinatal
mortality rates are low when
corrected for congenital anomaly,
prematurity, and manipulative vaginal
delivery
Face presentation
Definition

 The fetal head is

fully deflexed from
the longitudinal
axis
 This presentation
occurs in about
0.2% of all
deliveries
The attitude of fetuses’ head

occiput bregma brow face

presentation presentation persentation persentation

flex Not flex deflextion extension

Not extention
 12

9.5

13.5
•The anteroposterior diameter of the deflexed fetal head exceeds the average
9.5 cm of the suboccipitobrematic diameter in vertex presentation.
•The submentobregmatic diameter is only slightly larger than the 9.5 cm
suboccipitobregmatic diameter
Fetal position in face presentation

Symphyasis
pubis

sacrum
Fetal position in face presentation is determined by using the
mentum as the fetal point of reference to the maternal pelvis.
Causative factors

 Congenital malformations (particularly

anencephaly)
 Cephalopelvic disproportion
 Prematurity
 Grand multiparity
Diagnosis

 The fourth maneuver of Leopold

 Vaginal examination
 ultrasonography
The fourth maneuver of Leopold Vaginal examination
Differential Diagnosis

Breech presentation
 Face presentation may be distinguished
from breech presentation by
identification of the mouth and both
malar eminences in triangular
configuration
Mechanism

The mechanism of labor in

these cases consists of the
cardinal movements of
descent, internal rotation,
and flexion, and the
accessory movements of
extension and external
rotation.
Prognosis & Treatment
 The prognosis for vaginal delivery is guarded
for face presentation
 The submentobregmatic diameter is only
slightly larger than the 9.5 cm
suboccipitobregmatic diameter, but
complications generally arise with
simultaneously occurring pelvic contraction or
a persistent mentum posterior position
Mentum posterior positions

 Mentum posterior positions in average-

size fetuses are not deliverable vaginally
as they are unable to extend
A persistent mentum posterior position

Face presentation. The occiput is the longer end of the head lever. The chin is
directly posterior. Vaginal delivery is impossible unless the chin rotates anteriorly.
At the same time, the skull undergoes considerable molding, manifested by an
increase in length of the occipitomental diameter of the head
Mentum posterior positions

 Arrested labor is typical when

spontaneous rotation to the mentum
anterior position fails to occur
 There is little or no place for manual
flexion of the fetal head or manual
rotation from the mentum posterior
position to the mentum anterior position
Mentum anterior positions
 Oxytocin augmentation
With mentum anterior positions, oxytocin
augmentation may be used for arrested labor if
cephalopelvic disproportion can be ruled out
 Delivery may be accomplished by
 Spontaneous vaginal delivery
 Use of low forceps to rotate to the mentum anterior
position
 Cesarean section for arrested labor
FACE PRESENTATION

Edema in face presentation

Edema may sometimes significantly distort the face.
Abnormal fetal lie
Definition
 In transverse or
oblique lie, the long
axis of the fetus is
perpendicular to or at
an angle to the
maternal longitudinal
axis.
TRANSVERSE LIE
 When the long axis of the fetus is approximately
perpendicular to that of the mother

:obligue lie, unstable lie

:shoulder-over the pelvic inlet

head-in one iliac fossa
breech-in the other iliac fossa
 Abnormalities in axial lie
 occur overall in about 0.33% of all deliveries
 occur 6 times more frequently than normally
in premature labors
Causative factor

 Grand multiparity
Unusual relaxion of the abdominal wall
resulting from high parity
 Prematurity
 Pelvic contraction
 Abnormal placental implantation
Placenta previa
 Excessive amnionic fluid
TRANSVERSE LIE
 Diagnosis
 Inspection
 wide abdomen
Ut fundus extends to only slightly above umbilicus
 Palpation (Leopold’s maneuvers )
 no fetal pole in the fundus
ballottable head in one iliac fossa
breech in the other
 back
 anterior-> (hard resistance plane)
 posterior-> irregular nodulations representing small parts
 Be confirmed by real-time ultrasound scanning
TRANSVERSE LIE
 vaginal examination
 the side of the thorax
 further dilatation: scapula or clavicle

 axilla: shouler direction

 laterin labor
 shoulder become tightly wedged in the pelvis

 a hand and arm frequently prolapse

TRANSVERSE LIE

 Course of labor
spontaneous delivery of a fully developed
infants is impossible with a persistent
transverse lie
TRANSVERSE LIE

<neglected transverse lie>

 After ROM, labor continue
fetal shoulder is forced into the pelvis, the
corresponding arm frequently prolapse
 After some descent
shoulder is arrested in pelvis, with the head is in
the one iliac fossa and breech in the other
 As labor continues
 the shoulder is impacted
firmly in the upper part of
the pelvis
 contracts vigorously
 After a time
 a retraction ring rises
increasingly higher

 if not promptly managed

 uterine rupture
 mother & fetus die
conduplicato corpore
if small fetus(<800g), large pelvis
in spontaneous delivery
->the head and thorax pass through the pelvic
cavity at the same time
TRANSVERSE LIE

Prognosis
:maternal risk, fetal hazard: increased
:even with the best care, morbidity is incereased
->placenta previa, cord prolapse
Treatment
 External cephalic version
conversion to a longitudinal lie
(before or early labor)
 with the membrane intact,
no indication of cesarean
delivery
 Only after 39 weeks
because of spontaneous
conversion to a longitudinal
lie
 next several contraction: fix
the head in the pelvis
(during the early labor)
 Prompt low vertical cesarean delivery
 the onset of active labor
 cesarean-vertical incision

difficulty in extraction of the fetus

(not foot or head on incision site)
Compound presentation
Compound presentation

A prolapsed extremity
alongside the
presenting part
constitutes compound
presentation.
 Compound presentation complicates
about 0.1% of deliveries
 Prematurity and a large pelvic inlet are
associated clinical findings
Diagnosis

 Physical examination
 Compound presentations are often
diagnosed during physical examination and
investigation for failure
 Most commonly, a hand is palpated beside
the vertex
 Vaginal delivery
 Labor
in most of these patients will end in
uncomplicated vaginal delivery
 Cesarean section
 Cesareansection should be done in the
presence of dystocia or cord prolapse
 Attempts to reposition the fetal
extremity are discouraged, except
for gentle pinching of the digits to
determine whether the fetus will
retract the extremity.
Fetal Macrosomia
Definition

 Excessive fetal size

 LGA implies a birth weight greater than the
90th percentile
 Macrosomia implies growth beyond a
certain size, usually 4000-4500 g,
regardless of gestational age
 It occurs in about 5% of delivery
Risk factors
Associated risk factors
 maternal diabetes
 maternal obesity (>70kg)
 excessive maternal weight gain (>20kg)
 postdate pregnancy
 previous delivery of a macrosomic infant

However, less than 40% of macrosomic

infants are born to patients with identifiable
risk factors.
Diagnosis
 Abdominal palpation
 Diagnosis by abdominal palpation is notoriously
inaccurate

 Parameters from ultrasound

 A better estimated weight may be possible with
ultrasonography and standard measured
parameters
 Ultrasound also lacks accuracy, particularly with
increased fetal size
Estimated weight of fetus
(FW)
Fundal size (FS)
Abdomen circumference (AC) Maternal

FW = FS(cm) × AC(cm) ± 250g

FS(cm) ＋ AC(cm) ≥ 140(cm) 80% ≥ 4000g (cm)

FS(cm) ＋ AC(cm) ≥ 135 (cm) Fetal Macrosomia

BPD ＋ FL ≥ 17 (cm) is possible
Estimated weight of fetus (FW)
Ultrasound
BPD≥8.7cm FL≥6.9cm FW ＞ 2500g

BPD≥9.6cm FL≥7.6cm 80% FW ＞ 3500g

FW= BPD(cm) × 900 - 5200g Error±250g

Prognosis

 Perinatalmortality
 Shoulder dystocia
While morbidities to infant and mother increase with
increasing size between 4000 and 4500 g, perinatal
mortality for fetuses weighting more than 4500 g is
about fivefold higher than in normal term infants, and
incidence of shoulder dystocia is at least 10% in this
group.
 SHOULDER DYSTOCIA
Incidence
:varies depending on the criteria used for diagnosis
:0.9%ture shouder dystocia-0.2% (1987)
:maneuvers were required
so, current report-0.6~1.4%
#increasing factor(1960-1980)
:increasing birthweight
:shoulder-to-head, chest-to head disproportions
:increased attention
 SHOULDER DYSTOCIA
 Use of maneuvers – define shoulder dystocia
:but, use of one or more maneuvers-NO diagnosis
:TIME INTERVAL (head to body)
-normal: 24 seconds
-shoulder dystocia: 79seconds

 exceeding 60 seconds: define shoulder dystocia

 SHOULDER DYSTOCIA
 Shoulder dystocia drill
1.call for help
2.generous episiotomy
3.suprapubic pressure
-simple, only one assistant
-while normal downward traction
4.McRoverts maneuver
-two assistants
-resolve most case
-if fail, next steps may be attempted
 SHOULDER DYSTOCIA
5. the Woods screw maneuver
6. posterior arm delivery is attempted
7. other technique
-Zavanelli maneuver
-fracture of ant. clavicle, humerus
Fetal Malformation
 Fetal
malformation may cause dystocia,
primarily through fetopelvic disproportion
Fetal anomalies

 hydrocephalus
 with an incidence of 0.05%
 enlargement of the fetal abdomen
 distended bladder
 ascitesabdominal neoplasms

 other fetal masses

 Meningomyelocele

 cystosarcoma.
Fetal abdominal dystocia at 28
weeks caused by immensely
distended bladder. Delivery was
made possible by expression of
fluid from bladder through
perforation at umbilicus. Median
sagittal section shows interior of
bladder and compression of
organs of abdominal and thoracic
cavities. A black thread has been
laid in the urethra. ( From
Savage, 1935.)
Management

Management is determined by the

severity of the disorder and its
prognosis.