Tag: labor and delivery

The Left Mentoanterior Position: Understanding Fetal Presentation during Labor

JiangRuoan

– Face presentation is a cephalic presentation in which the head is completely extended.
– The incidence of face presentation is about 1 in 300 labours.
– Primary face presentation occurs during pregnancy and may be caused by factors such as anencephaly, loops of the cord around the neck, foetal neck tumors, hypertonicity of neck muscles, dolicocephaly (long antero-posterior diameter of the head), dead or premature foetus, or idiopathic causes.
– Secondary face presentation occurs during labour and may be due to factors such as contracted pelvis, pendulous abdomen, marked lateral obliquity of the uterus, further deflexion of brow or occipito-posterior positions, or other malpresentations such as polyhydramnios and placenta praevia.
– Left mento-anterior (LMA) and right mento-anterior (RMA) are more common positions of face presentation.
– Diagnosis during pregnancy is difficult, but the back is difficult to feel and the limbs may be felt more prominently in mento-anterior position. Ultrasound or X-ray can confirm the diagnosis.
– Diagnosis during labour is done through vaginal examination, which shows identifying features such as supra-orbital ridges, malar processes, nose, mouth, and chin.
– Late in labour, the face may become oedematous (tumefaction), which can be misdiagnosed as a buttock (breech presentation). Differentiating factors include the formation of a triangle with foetal mouth and malar processes as apexes, anus on the same line as ischial tuberosities, feeling of a hard gum through the mouth, and no hard object through the anus.
– The mechanism of labour in mento-anterior position involves descent.
– Engagement by submento-bregmatic diameter: 9.5 cm
– Submental region hinges below the symphysis in flexion position
– Submento-vertical diameter: 11.5 cm
– Biparietal diameter does not pass the plane of pelvic inlet until the chin is below the level of the ischial spines and the face begins to distend the perineum
– In about 2/3 of cases, long anterior rotation of 3/8 circle occurs during mento-posterior position
– In about 1/3 of cases, deep transverse arrest of the face, persistent mento-posterior, or direct mento-posterior occur during mento-posterior position
– Direct mento-posterior cannot be delivered due to obstruction caused by the length of the sacrum and neck
– Management of labour includes excluding foetal anomalies and contracted pelvis
– Spontaneous delivery usually occurs in mento-anterior position during second stage of labour
– Forceps delivery and episiotomy may be indicated in prolonged second stage of labour in mento-anterior position
– Wait for long anterior rotation of 3/8 circle in mento-posterior position during second stage of labour
– Oxytocin is used to compete inertia during this period if there are no contraindications
– Caesarean section is the safest option if long anterior rotation fails or there is foetal or maternal distress
– Manual rotation and forceps extraction or rotation and extraction by Kielland forceps are alternative methods, but are hazardous and not commonly used
– Craniotomy may be performed if the foetus is dead
– Complications may occur, refer to complications of malpresentations and malposition for more information.
– There is an increased risk of trauma to the baby in face presentation, so internal manipulation, vacuum extractors, and manual extraction should be avoided.
– Abnormalities in fetal heart rate are more common in face presentation. Monitoring is crucial during labor.
– Complications of face presentation include prolonged labor, facial trauma, facial edema, skull molding, respiratory distress, spinal cord injury, abnormal fetal heart rate patterns, and low Apgar scores.
– Informed consent should be obtained from the mother, and failure to do so is considered negligence.
– Forceps and oxytocin used during labor can put a baby at risk of complications. Forceps can cause head injuries and oxytocin can deprive the baby of oxygen due to strong contractions.
– Mothers should be given the option of a C-section if facing complications.
– Face presentation babies should be closely monitored and delivered by an experienced physician.
– If negligent practices cause injury to the baby, it can be considered medical malpractice. ABC Law Centers specialize in birth injury cases and offer free legal consultations.

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Left Occipitoposterior: Understanding the Causes, Symptoms, and Treatments

JiangRuoan

– This article describes a randomised clinical trial being conducted to evaluate the effects of different positions on the outcome of occipitoposterior (OP) position during labor.
– The study will compare the hands and knees position with expectant management (no intervention).
– The study will only include nulliparous and multiparous women during the first stage of labor with a cervical dilatation between 2 to 9 cm, a singleton pregnancy at term (≥ 37 weeks’ gestation), and an OP position diagnosed by ultrasound.
– Women under 18 years old, with limited understanding of French, or who have attempted hands and knees positions previously during labor are excluded from the study.
– Randomisation will be performed using a web-based system and the ratio for hands and knees versus expectant management is 1:1.
– The study interventions involve women in the hands and knees position group choosing one of six positions described by Dr. de Gasquet.
– There are six fitted positions that can be used, with three important points to be observed: resting on the knees and hands if necessary, thrusting the abdomen forward, and keeping the back stretched.
– A pillow can be used for comfort, and the woman can choose to place her abdomen on a cushion or leave it unsupported.
– All midwives in the delivery room have been trained in managing the OP position using specific hand and knee positions.
– In the expectant management arm, women will receive usual care and have the option to adopt a hands and knees’ position after one hour. The position of the woman during this hour will be recorded.
– Participants in both groups will complete a questionnaire on perceived pain and comfort, and fetal head position will be verified one hour after randomization or at delivery.
– The primary outcome measure is fetal head in anterior position.
– The study aims to compare different maternal positions during labor and their impact on fetal head rotation.
– The study will assess the effectiveness of various positions on fetal head rotation, comfort of maternal positions, pain perception, duration of labor stages, mode of delivery, perineal status, and neonate outcomes.
– Data analysis will be performed using statistical tests such as t-tests, chi-square tests, and non-parametric tests.
– A sample size of 438 women is needed to show a statistically significant difference in the incidence of the main outcome measure.
– The study estimates that around 300 eligible women per year will be proposed for study entry, and the required sample size could be reached in around 35 months.
– The study is expected to be completed in June 2014.
– The study protocol has been approved by the institutional ethics committee, and safety considerations for mothers and fetuses will be closely monitored.
– The study ensures that women have the right to withdraw consent without impacting the quality of care or staff attitude.
– Data will be kept confidential and participants will be identified with a number.
– The study results will be reported anonymously.

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