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Marynes T. Ramil

Fetal Presentation

It is the part of the fetus that liesclosest to or has entered the truepelvis. Cephalic presentations arevertex, brow, face, and chin. Breechpresentations include frank breech,complete breech, incomplete breech,and single or double footling breech.

Shoulder presentations are rare andrequire cesarean section or turningbefore vaginal birth. Compoundpresentation involves the entry of morethan one part in the true pelvis, mostcommonly a hand next to the head.

A.)Cephalic presentation means headfirst. This is the normal presentation and occurs in about 97% ofdeliveries. There are different types of cephalic presentation, whichdepend on the fetal attitude. If the fetus' head is extended back, thenthe chin, face, or forehead will exit first depending on the degree ofextension. This is not considered preferable since this part of the fetalhead is not the smallest, thus increasing the difficulty of the birth.Preferably the fetal head is flexed down to the chest resulting in a"vertex" delivery, in which the crown of the head exits first.

Importance of cranial flexion is emphasized bynoting the increased diameters presented tothe birth canal with progressivedeflection. A.Flexed head. B. Militaryposition. C, D.Progressive deflection. (O'GradyJP, Gimovsky ML, McIlhargie CJ [eds]: Operative

Obstetrics. Baltimore, Williams & Wilkins, 1995)

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B.)Breech presentation is considered abnormal and occurs about 3% ofthe time and it includes frank breech, complete breech, incompletebreech, and single or double footling breech.

Breech Presentations:

B.1) Frank breech means the buttocks are presenting and the legs are upalong the fetal chest. The fetal feet are next to the fetal face. This is the

safest arrangement for breech delivery.

B.3.) Footling breechmeans either one foot ("Single Footling") or both feet("Double Footling") is presenting. This is also known as an incomplete

breech.

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B.4.)Complete breech means the fetal thighs are flexed along the fetalabdomen, but the fetal shins and feet are tucked under the legs. Thebuttocks is presenting first, but the feet are very close. Sometimes duringlabor, a complete breech will shift to an incomplete breech if one or both ofthe feet extend below the fetal buttocks. While many breech fetuses deliver

vaginally without incident, this presentation is associated with an increasedrisk of:Fetal mechanical injury (fractures, nerve damage, and soft tissue injuries)Fetal asphyxia due to umbilical cord prolapse and obstruction, and fetal headentrapment.For these reasons, many breech babies are delivered by cesarean section ,and some obstetricians feel that all breech babies should be delivered in thisway.

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*Complications of breech

*Correcting breech

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C.)Shoulder presentation means that the fetal shoulder is trying tocome out first. Shoulder presentations are rare and require cesareansection or turning before vaginal birth. The shoulder, arm, or trunk mayexit first if the fetus is in a transverse lie. This type of birth occurs lessthan 1% of the time. Transverse lie is more common with prematuredelivery or multiple gestation.This is a more advanced form of

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transverse lie and is undeliverable vaginally. In military settings,position and presentation can be made by:

Pelvic ExamAbdominal Exam (Leopold's Maneuvers)Single x-ray of the abdomen

Ultrasound if available.

D.)Compound presentation means that a fetal hand is coming out withthe fetal head. Compound presentation involves the entry of more than onepart in the true pelvis, most commonly a hand next to the head. Compoundpresentation means that a fetal hand is coming out with the fetal head. Thisis a problem because:The amount of baby that must come through the birth canal at one time is

increased. There is increased risk of mechanical injury to the arm andshoulder, including fractures, nerve injuries and soft tissue injury. Acompound presentation may be resolvable if the fetus can be encouraged towithdraw the hand, for example.

If the fetus and arm are relatively small in comparison to the maternalpelvis, vaginal delivery may still be possible, but with some risk of injury to

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the arm. If the fetus and arm are relatively large in comparison to thematernal pelvis, obstructed labor will occur and a cesarean will be needed.

E.) Transverse

lie means the fetusis oriented from oneside of the motherto the other andneither the head northe butt is comingout first. If the fetusremains in atransverse lie, itcannot deliverdeliver vaginally as

the diameter of thefetal presenting part(the whole body, inthis case) cannotdescend through thebirth canal.

If labor is allowed tocontinue for enough timewith the fetus intransverse lie, the uteruswill rupture. Even before

the uterus ruptures, thereis an increased risk in thispresentation for prolapsedumbilical cord. For thesereasons, women found tohave a transverse lie inlabor will usually have acesarean section. There are someexceptions to this

indication for cesarean section:

If labor is occurring during the middle trimester and fetus is not consideredviable, it may be possible for this very small and fragile fetus to compressenough to squeeze through the pelvis. In this case, fetal survival would notbe an issue.It may be possible to perform an external version, during which youmanipulate the fetus, converting it to either breech or cephalic presentation.This is often more difficult than it sounds, particularly during labor, andcarries some risk of injury to the fetus, placenta, umbilical cord, or uterus.

http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/AbnormalPresentation.htm#Transverse%20Liehttp://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/AbnormalPresentation.htm#Transverse%20Liehttp://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/ProlapsedCord.htmhttp://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/ProlapsedCord.htmhttp://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/AbnormalPresentation.htm#Transverse%20Liehttp://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/AbnormalPresentation.htm#Transverse%20Liehttp://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/ProlapsedCord.htmhttp://www.brooksidepress.org/Products/Military_OBGYN/Textbook/AbnormalLandD/ProlapsedCord.htm

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In the case of twins, it would be acceptable to allow labor, even though thesecond twin is in transverse lie, anticipating that after delivery of the firsttwin, you would reach in and perform an internal version, converting thetransverse lie to cephalic or breech presentation prior to delivery.Some predisposing factors for a transverse lie include:

Grand multiparity - more than 5 term pregnancies.Placenta previaBony abnormalities of the pelvisPelvic kidneyOther pelvic mass Transverse lie occurs frequently in early pregnancy, when it is of noconsequence. At 16 weeks gestation, about half of all pregnancies will betransverse lie. This number steadily falls as pregnancy advances and theincidence of transverse lie by the 28th week is well below 10%. It fallssteadily thereafter.Whenever a fetal transverse lie is encountered near term or in labor,

evaluate the patient carefully with ultrasound to determine if there are anypredisposing factors, such as a placenta previa or pelvic kidney that couldmodify your management of the patient. So long as a placenta previa is notpresent, many obstetricians will check the patient's cervix at frequentintervals to detect early cervical dilatation and the consequential increasedrisk of cord prolapse. Sometimes, these patients are delivered early byscheduled cesarean section to avoid that risk.

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Fetal Descent Stations (Birth Presentation) -

Medical Illustration, Human Anatomy Drawing

Fetal Descent Stations (Birth Presentation). This medical illustrationpictures a single detailed view of the female abdomen during labor, withpelvic bones, uterus, vaginal canal and a large 41 week fetus in the vertex

position at the -2 station. The cervix is shown and labeled at a 10cm dilation.Identified within this view are stations of descent. This exhibit is typical as itfeatures the commonly used descent stations from -3, 0, +3.

Definition: Fetal StationZero Station Notation (presenting part level)Presenting part in relation to ischial spinesReported in centimeters from ischial spines

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Negative numbers are behind the ischial spinesEngagementRefers to presenting part meeting pelvic floorOccurs at 0 stationStep 1: Fetal Descent

Fetal head position on abdominal palpationHead fixed: 3/5 palpable abdominallyHead engaged: 2/5 palpable abdominallyFetal Heart Tones change position (towards pelvis)

**It is the 2nd Mechanisms of Labor.

The Mechanisms of Labor occur to the fetus during delivery. Knowledge ofthese mechanisms enables the nurse to proceed with normal delivery anddetect if any abnormalities are occurring during delivery that can enable the

health care team to perform measures that could prevent possiblecomplications. You can be guided by the acronymEDFIERERE.E = EngagementIt is the mechanism wherein the fetus engages to the pelvis. It is also calledlightening or dropping.D = DescentDescent is the mechanism where the fetal head begins its journey throughthe pelvis. Assessment measurement is termed as station.

Stations of Presentation - Medical Illustration, HumanAnatomy Drawing

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Depicts stages of birth presentation for a full-term fetus. The graphicdisplays a baby in an occiput posterior (head down, facing outward)presentation at the +2 station. Labeled anatomical strutures includethe uterus, placenta, pubic symphysis and sacrum. Also labeled arethe various stages of presentation (-3, -2, -1, 0, +1, +2, +3) asrepresented by lines drawn from the pubic symphysis radiating towardthe posterior of the mother's pelvis.

Stations of Presentation - Fetal Head Positions During Descent -Medical Illustration, Human Anatomy Drawing

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Stations of Presentation - Fetal Head Positions. This custom medicalexhibit reveals a single detailed view of the pregnant femaleabdomen during labor, pelvic bones, uterus, vaginal canal and fetusin utero. Identified within this view are stations of descent. Thisexhibit is somewhat atypical as it features an asymmetricalcombination of descent station scales. Normally stations are either (-

5, 0, +5) or more commonly (-3, 0, +3). This particular illustrationshows a (-3, 0, +5) combination.

Stations of Presentation: Fetus at 0 Station - Medical Illustration,

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Human Anatomy Drawing

This medical exhibit identifies the levels (stations) of presentation of the fetalhead at birth. This exhibit pictures a side cut-away view of the maternal pelvis,abdomen and the fetus progressively descending to stage 0.

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Fetus at +2 Station In Occiput Posterior Presentation - MedicalIllustration, Human Anatomy Drawing

Labor and Delivery - Fetus at +2 Station. This full color medical exhibit depictsthe fetal descent stations of presentation in a sagittal cut-away view of thepelvis. The stations are represented by black lines and the baby is shown at the+2 station.

***Other Terminologies and ProceduresCrowning. The fetal head distends the labial and perineal tissue and the

anus is stretched wide.Fetal attitude is the relationship of the fetal parts to each other. Anexample is the "military" attitude, in which the fetal head is not flexed andthe chin is not on the chest as usual but is held straight up.Fetal lie the relationship of the long axis of the fetus to the long axis of themother.

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Ritgen Maneuver. Pressure is applied to the fetal chin through theperineum at the same time pressure is applied to the occiput. This aids themechanism of extension as the fetal head comes under the symphysis.