00:01
Now let's discuss
malpresentation of the fetus.
00:05
So here's our patient.
00:06
She's a 27 year old gravida 3
para 2 female that presents
for her 36 week prenatal visit.
00:14
Her pregnancy has
been uncomplicated.
00:16
She's had two prior
vaginal deliveries.
00:18
By Leopold's, the fetal position
is felt to be in the breech
presentation.
00:23
Ultrasound confirms the fetus
is frank breech.
00:27
How would you counsel this
patient on her delivery options?
Let's go through
the lecture to see.
00:32
First let's talk
about malpresentation.
00:35
We can have Face presentation,
Brow presentation or Breech.
00:40
Now in a normal vaginal delivery
in the cephalic presentation,
the fetal head is flexed
and in the vertex presentation.
00:49
With that the fetal head is
about 9 and half centimeters.
00:53
That's what needs to
pass through the pelvis.
00:55
The pelvis at it's widest diameter
is about 10 centimeters.
00:59
When the fetal head is in
the face presentation
or the brow presentation,
you have a large diameter trying
to get through the pelvis.
01:08
If the brow presentation
particularly, there's about
14 centimeters of the fetal head
trying to traverse the pelvis.
01:14
As you can see here
in the picture.
01:16
So because of that brow
presentation cannot be
delivered vaginally.
01:20
With face presentation you also
have a large diameter trying
to get through the pelvis
but not as large as brow.
01:26
And sometimes face presentation
can be delivered vaginally.
01:29
Now, with the face
presentation, when the fetus is
mentum anterior, you can see
that as the head goes through
the pelvis, then the head
is allowed to flex,
meaning that the chin
touches the chest.
01:44
That creates a fetal diameter
about 9 and half centimeters.
01:47
Again this can be
delivered vaginally.
01:50
However, when the fetus
is in the mentum posterior
presentation, you have a larger
diameter trying to get through
the pelvis.
01:58
The head is completely deflex.
02:00
Meaning the chin is
looking to the ceiling.
02:02
And so you have a larger
diameter that just cannot
pass through the pelvis.
02:05
So mentum posterior face
presentation cannot be
delivered vaginally.
02:11
Now we have three types
of breech presentation.
02:13
We have frank breech, where you
can see the legs are straight.
02:17
Complete breech, where
the legs are folded.
02:20
And then we can have footling
breech, where one foot is
actually trying to pass
through the pelvis.
02:26
Now with breech presentations
we don't usually recommend
a vaginal delivery.
02:30
Why is that?
Well, there is definitely some
risks to go along with having
a vaginal breech delivery.
02:35
First is cord prolapse.
02:37
Meaning the cord can come
through before the baby does
and this can lead to some fetal
heart rate abnormalities.
02:44
Then we have fetal
head entrapment.
02:46
If you think about it,
the largest part of the fetus
is the head.
02:50
So if it is the last part to
come through, the cervix is not
dilated enough so that
the head can pass.
02:55
This can lead to fetal head
entrapment and that can lead to
hypoxia and death of the fetus.
03:01
Also with vaginal breeches, when
we deliver those we have risk
of fetal injury as
well as fetal death.
03:09
Now with breech presentation,
there are two things
that we recommend.
03:14
Two routes of delivery.
03:15
One is external cephalic version
and next is scheduled
cesarean section.
03:20
Let's talk about those are in
a little bit more detail.
03:22
So what is an external cephalic
version, is the process by which
the obstetrician physically
turns the fetus from breech
to cephalic presentation.
03:32
And you can see here in
the diagram,
that the obstetrician's arms
and hands are on the belly
and they are physically turning
that baby all the way around.
03:44
Now we usually recommend doing
this at 37 weeks
and not prior to that.
03:49
We'll just talk about
why in just a second.
03:51
The patient has to have
no contraindications
to a vaginal delivery.
03:55
Because again that's the point
of doing the external cephalic
version so that you can
have a vaginal delivery.
04:00
And because some of the risks
that are associated with
external cephalic version,
you have to have
the availability to perform
an emergency C-section.
04:08
So with external cephalic
version, again this should be
performed at 37 weeks
because this is term.
04:17
We don't want to cause the
patient to go into labor
before 37 week with the things
that we are doing.
04:23
So for that reason we do not
perform external cephalic
version until the patient
is 37 weeks.
04:29
Now, what are the risks that
are associated with external
cephalic version.
04:34
First, placental abruption.
04:36
Because you are rotating
the fetus, you can disrupt
the placenta causing it to
prematurely separate
from the uterus.
04:43
Next is rupture of membranes.
04:45
Again because you're
manipulating the fetus, that
means you are also manipulating
the amniotic sac and that can
cause rupture of membranes.
04:55
Cord prolapse.
04:56
Again when you are manipulating
the fetus, you can cause
the cord to come out.
05:00
And this will necessitate
a emergency C-section.
05:05
Now because you are moving
the baby around,
sometimes the babies don't like
that and you can experience
fetal distress.
05:12
Sometimes that will resolve,
sometimes it does not resolve
and that necessitate an
emergency C-section as well.
05:19
And then another risk
is fetal hemorrhage.
05:21
Again, if you disrupt
the placenta or the cord through
the external cephalic version
that can cause hemorrhage
and that also necessitates
an emergency C-section.
05:32
Now if a patient decides she
does not want to do an external
cephalic version or if external
cephalic version is
contraindicated or if it is
not successful,
then elective C-section is performed
at 39 weeks gestation.
05:47
So far our case, as we mentioned
before she is a patient that's
presenting at 36 weeks
with a breech presentation.
05:56
So what are the things
that we can offer her.
05:58
Again this patient is
a candidate for
an external cephalic version.
06:02
She's had two vaginal deliveries.
06:03
This again makes her
a great candidate.
06:06
But we do need to discuss
with her the risk, benefits
and alternatives of
doing that procedure.
06:12
So back to our patient that
presented 36 weeks with
her breech presentation.
06:16
Which of the following is not a
risk of breech vaginal delivery?
Is it A. Cord prolapse.
06:23
B. Head entrapment.
06:25
C. Postpartum hemorrhage
or D. Fetal death.
06:29
The answer is postpartum hemorrhage.
06:32
Again because we are delivering
the baby vaginally the cord can
come down before the baby
causing a cord prolapse.
06:40
As we stated before the head is
the largest part of the baby,
so if it is the last thing
to come out,
you can have head entrapment.
06:48
And because of these risks fetal
death is also a risk associated
with breech vaginal delivery.
06:52
However, postpartum hemorrhage
is not.