9. Malpresentation
all presentations of the fetus other than vertex [breech,
brow, face, shoulder,etc]
Malposition
abnormal positions of the vertex of the fetal head relative
to the maternal pelvis
9
10. Epidemiology
Breech presentation occurs in 3-4% of singleton pregnancies
Face presentation occurs in 0.5-3 in 1000 live births
Brow presentation occurs in 0.02% of singleton pregnancies
Shoulder presentation occurs in 1 of every 300 births
10
16. Breech Presentation
Types, Antenatal Management, External Cephalic Version (ECV), Mode of
Delivery, Vaginal Breech Delivery, Technique, Complications
16
17. Types
Extended (Frank) Breech
Most common
Flexed (Complete) Breech
Less common;
Footling Breech
Foot presents at cervix
Risk for cord & foot prolapse
Least common
Kneeling Breech
Extremely rare
17
18. Extended (Frank)
Breech
▪ Makes up 60-70% of Breech Presentations
▪ Baby’s bottom comes first
▪ Legs are flexed at the hip
▪ extended at the knees
▪ (feet near Ears)
18
19. Complete Breech
▪ Makes up around 15%
▪ Baby’s Hips and Knees are flexed
▪ Cross-Legged sitting
▪ Feet are at the Bottom
19
20. Footling Breech
▪ Makes up 25%
▪ One or both feet come first
▪ Bottom at a higher position
▪ Rare but common with premature babies
20
21. Kneeling Breech
▪ The baby in a kneeling position
▪ With one or both legs extended at the hips
▪ Flexed at the knee
▪ Extremely Rare
21
22. Antenatal
Management
▪ Confirm by U/S if suspected @ or after 36 wks
▫ Fetal biometry
▫ Amniotic fluid volume
▫ Placental site
▫ Position of fetal legs
▫ Look for anomalies
▪ Management options:
▫ External Cephalic Version (ECV)
▫ Vaginal Breech Delivery
▫ Elective Caesarean section
22
23. External Cephalic
Version
▪ Straightforward & safe; should not last more than 10 mins
▪ Success rates ~50%
▪ @ or after 37 wks
▪ Should be done by experienced obstetrician at / near delivery facilities
▪ Should be performed with a tocolytic (medication to suppress premature
labor) [nifedipine]- improves success rate
▪ Bladder should be emptied beforehand
▪ Woman is laid flat with L lateral tilt
▪ With U/S guidance, breech is elevated from pelvis & 1 hand manipulates it
upward in direction of forward role; other hand applies gentle pressure to
flew fetal head & bring it down to maternal pelvis
▪ Fetal HR trace should be performed before & after
▪ *administer anti-D if woman is Rhesus-negative
23
25. Risks for ECV
▪ Placental Abruption
▪ Premature rupture of the membranes
▫ Can lead into Preterm delivery that’s why it’s done
at 36+ weeks of gestation
▪ Transplacental Hemorrhage
▪ Fetal Bradycardia
25
27. Vaginal Breech Delivery
Associated with 3% increased
risk of death / serious morbidity
to baby
Some still choose vaginal
breech delivery / undergo
precipitous labor
Mode of
Delivery
Caesarean Section
Best method for delivering term
breech singleton baby
27
28. Vaginal Breech
Delivery
▪ Wait for spontaneous labor
▪ Vaginal Exam is done to not only to
assess the progress of labor
▪ If membrane is ruptured, do a vaginal
examination to immediately exclude
uterine cord prolapse
▪ If the membrane is not ruptured,
examination for cord presentation
28
▪ Do not rupture the membranes
▪ Examine and monitor the woman
regularly and adhere strictly to the
partogram
▪ Poor progress may occur if the
sacrum is posterior/ bigger baby
than expected
▪ If there is any delay, the baby
should be delivered via C-section
29. Vaginal Breech
Delivery
▪ Delivery of buttocks
▫ Occur naturally
▪ Delivery of the legs and lower Body
▫ Legs Flexed : Spontaneous Delivery
▫ Legs Extended : Pinard’s Maneuver
▪ Delivery of the shoulders
▫ Loveset’s Maneuver
▪ Delivery of the Head
▫ Burns Marshall Method
▫ Mariceau-Smellie-Veit manoeuvre
▫ Forceps delivery of the aftercoming head
29
30. Pinard’s Manoeuvre
▪ In breech with extended legs
▪ Once groin is visible gentle pressure can be applied to
abduct the thigh and reach the knee
▪ The knee can be flexed with pressure in the popliteal
fossa and leg is delivered
▪ Anterior leg is first
30
31. Loveset’s Manoeuvre
▪ Procedure is used to automatically correct any upward
displacement of arms
▪ Loveset’s maneuver - the baby’s trunk is made to rotate with
downward traction holding the baby at the iliac crest so that
posterior shoulder comes below symphysis pubis and the arm is
delivered by flexing the shoulder followed by hooking at the elbow
and flexing it followed by bringing down the forearm “like a
handshake”
▪ The same procedure is repeated by reverse rotation of 180
degrees so that anterior shoulder comes below the symphysis
pubis
31
32. Burns Marshall
Method
▪ Delivery of the aftercoming head
▪ Common to allow the baby to hang for a minute
▪ Assistant gives a suprapubic downward and pressure to
promote the head
▪ Once the nape of neck is visible, identified by the hairline,
the baby’s trunk is gently lifted and swung toward mother’s
abdomen holding the baby just above the ankle through 180
degrees
▪ Left hand guards and slips the perineum over fetal mouth
▪ As the mouth is born, air passage is cleared of mucus and
now depressing the trunk, allowing for the head to be born
32
34. Mariceau-Smellie-Viet
Manoeuvre
▪ Jaw Flexion and should traction - JFST
▪ Here the baby is allowed to rest on the left supinated forearm of the
obstetrician, with the limbs hanging on either side
▪ Left index and middle finger is placed on the malar bones, while the
right index and ring fingers are placed on the respective shoulders
and the middle finger on the suboccipital region
▪ To Achieve flexion, traction is now given downward and backward
direction and simultaneous suprapubic pressure is maintained by
the assistant until the nape of the neck is visible
▪ Baby is pulled in upward and forward direction so that the face is
born and by depressing the trunk - the head is then born
34
37. C-section Continued
▪ Now- there is a trend to deliver all breeches at term by
C-section, due to the chance of prolonged labor which
can lead to other complications like hypoxia and/or death
▪ Results to do not apply to
▫ Twin pregnancy with breech presentations
▫ Preterm breech deliveries
▫ Breech presentations that arrive late
▫ Advanced Labor
▪ In these situations, baby should delivered vaginally
37
39. Transverse Lie
-A transverse lie occurs when the
fetal long axis lie perpendicular to
that of maternal long axis. The baby’s
back might be positioned down
facing the birth canal with one
shoulder pointing towards the birth
canal.
- Causes are polyhydramnios,
abnormality of uterus, position of
placenta, twin or multiple
pregnancy, pelvic structure.
39
40. Oblique Lie
-An oblique lie occurs when fetal
body crosses the long axis of
maternal body at an angle close to 45
degrees.
-Causes are polyhydramnios, baby
too large for the pelvis, fibroids
present in uterus, abnormally shaped
uterus.
40
41. How to suspect?
-The diagnosis of transverse or oblique lie might be suspected by
abdominal inspection, abdomen often appears asymmetrical. The SFH
maybe less than expected and on palpation the baby’s head or buttocks
may be in the iliac fossa. Palpation over pelvic brim may reveal an Empty
pelvis.
-Woman in the labour with the baby’s lie anything other than
longitudinal will not be able to deliver vaginally. If c-section is not
performed, both mother and baby’s life will be at risk. Only exception to
this situation is for exceptionally preterm or small babies.
41
44. Face Presentation
▪ Head is
hyperextended
▪ Presenting part is
face
▪ Denominator is chin
(mentum)
▪ Between glabella &
chin
▪ Presenting diameter
is
submentobregmatic
(9.5 cm)
Etiology- Maternal
▪ Multiparity
▪ Lateral obliquity
of fetus
▪ Contracted
pelvis / CPD
▪ Flat pelvis
Etiology- Fetal
▪ Congenital
malformation
(anencephaly)
▪ Several coils of
umbilical cord around
neck
▪ Musculoskeletal
abnormality (spasm/
shortening of
extensor muscle of
neck)
▪ Tumors around neck
(congenital goiter)
44
45. Face Presentation
Diagnosis
▪ Is Caused by the hyperextension of the fetal head so
that neither the occiput not sinciput are palpable on
vaginal examination
▪ On abdominal examination, a groove may be felt
between the occiput and the back
▪ On vaginal examination, the face is palpated, the
examiner’s finger enters the mouth easily and the bony
jaws are felt
▪ Chin is a reference point in describing the head position
▪ Necessary to distinguish only chin-is anterior in
relation to the maternal pelvis from chin-posterior
positions 45
46. Face Presentation
Management
▪ Prolonged labor is common
▪ Descent & delivery of head by flexion may occur in
chin-anterior position
▪ In chin-posterior position, fully extended head is
blocked by sacrum– prevents descent & labor is
arrested → C sxn
Management of Chin-anterior
▪ Cervix fully dilated→ allow normal childbirth
▫ Slow progress w/ no signs of obstruction→
augmentation of labor
▫ Descent unsatisfactory→ forceps delivery
▪ Cervix not fully dilated→ augmentation of labor
46
47. Brow Presentation
▪ Brow presentation is caused by partial extension of the
fetal head so that the occiput is higher than the
sinciput
▪ MGT: of the fetus is alive or dead, has to be delivered
by C-section
▪ Do not deliver brow presentation by vacuum extraction,
outlet forceps, or symphysiotomy
47
48. Shoulder
Presentation
▪ Occurs as a result of transverse lie or oblique lie
▪ Predisposing factor- Breech Presentation
▪ Abdominal Examination, neither the head nor the
buttocks can be felt at the pubic symphysis pubis and
the head is usually felt in the flank
▪ On vaginal exam- a shoulder may be felt, but not
always. An arm maybe prolapsed and the elbow, arm,
or hand may be felt in vagina
▪ Use ultrasound examination
48
49. Shoulder
Presentation
Management
▪ Monitor for signs of cord prolapse
▫ Cord prolapses & delivery is not imminent→ C sxn
▪ Modern practice: persistent transverse lie in labor is
delivered by C sxn whether fetus is alive or dead
49
51. Compound
Presentation
Management
▪ Replacement of prolapsed arm
▫ Assist woman to assume knee-chest position
▫ Push arm above pelvic brim & hold there until
contraction pushes head into pelvis
▫ Proceed with management for normal childbirth
▪ If procedure fails / cord prolapse→ C sxn
51
53. A type of fetal position that can pose a risk or
obstacle to safe spontaneous vaginal delivery,
anything other than occiput anterior.
▪ Occiput posterior position
▪ Occiput transverse position
53
54. Fetal occiput points towards
the maternal sacral promontory
with face to pubis symphysis;
the fetus faces upward.
Difficult to deliver, large
episiotomy might be required.
Contractions are painful and
accompanied by backache.
Occiput posterior
position
Black
Is the color of ebony and of
outer space. It has been the
symbolic color of elegance,
solemnity and authority.
54
55. Occiput transverse
position
It is incomplete rotation from
occiput posterior to anterior,
results in head being in a
horizontal or transverse
position.
55
56. How to diagnose?
Palpation:
Fetal back is found on one side or difficult to
identity.
Fetal head is posterolateral and free above the
brim.
Auscultation:
Fetal heart best heard in the flank but descends to
just above the pubis as the head rotates and
descends.
56
57. Factors that favour
malposition
▪ Anthropoid or android pelvic brim
▪ Flat sacrum-transverse position
▪ Placenta on anterior uterine wall
▪ Narrow midpelvis
▪ Occiput Posterior more common in primigravida
▪ Pendulous abdomen in multipara (abnormally
relaxed anterior wall of the abdomen hangs over
the pubis)
57
58. Management
As occipito-posterior-position pregnancies often result in a long
labour, close monitoring is required.
Epidural and adequate fluids recommended.
If the head comes into a face-to-pubis position then vaginal
delivery is possible if there is a reasonable pelvic size.
Otherwise, forceps or caesarean section may be required.
Alternatives for delivery include manual rotation of fetal head
using Kielland's forceps(if occiput transverse), or delivery using
vacuum extraction. This is inappropriate if there is any fetal
acidosis because of the risk of cerebral haemorrhage.
A trial of forceps can be done but can be changed immediately
to cesarean if need arises.
58
60. Sources
▪ Malpresentations and Malpositions Information | Patient
▪ Obstetrics by Ten Teachers 19th edition
▪ Dewhurst’s Textbook of Obstetrics & Gynaecology 7th edition
▪ PPT - Malpresentation Malposition PowerPoint Presentation, free download - ID:2343401 (slideserve.com)
▪ Breech Presentation - Breech Births (americanpregnancy.org)
▪ Shoulder Presentation: Causes, Complications & Diagnosis (firstcry.com)
▪ PPT - Brow Presentation PowerPoint Presentation, free download - ID:3778069 (slideserve.com)
▪ Face presentation in delivery room: what is strategy? - PMC (nih.gov)
60
Notas do Editor
Presentation- lowest pole of fetus that presents to lower uterine segment & cervix
Normal position- vertex presents in occipitoanterior; head well flexed, presents smallest anteroposterior & lateral diameters & parietal eminences @ same lvl of pelvis
Malpresentation
Breech presentation
Antenatal mngmt of breech presentation
External cephalic version
Mode of delivery
Prerequisites for vaginal breech delivery
Technique
Complications
Other fetal presentations
Malposition- more applicable to cases of normal presentation
Occiput lies in posterior half of pelvis
Usually present slightly extended head with larger anteroposterior diameter (11.5 cm)
May also present w anterior / posterior asynclitism (parietal eminence in anterior half of pelvis & lower - ant async & post - vice versa)
MalpresentationMalposition
Definition • Malpresentation = Fetal presenting part other than vertex & includes breech, brow, transverse, face. • Malposition = Refers to positions other than an occipito-anterior position.
Commonest Presentation & Position Suboccipito-Bregmatic Extends from center of neck to bregma. Presentation: Vertex Attitude: Complete Flexion D = 9.5cm
Occiput anterior positions
MALPOSITION Malpositions include occipitoposteriorand occipitotransverse positions of fetal head in relation to maternal pelvis.
How to diagnose? • Palpation • Fetal back is found to one side or may be difficult to identified. • The fetal head is posterolateral and will be free above the brim. • Auscultation • The fetal heart best heard in the flank but descends to just above the pubis as the head rotates and descends. • VE • the membrane tend to ruptured early before the labour is establish if the membrane is intact they may protrude through the cervix giving finger-like forewaters.
Pendulous abdomen- in multiparae Anthropoid pelvic brim- favours direct O.P/O.A Android pelvic brim A flat sacrum-transverse position The placenta on the ant. uterine wall R.O.P Factors that favour malposition
Problems • Occiput Posterior - the baby's head faces the front of the mother's pelvis instead of turning toward the mother's back. The baby would then be delivered with the head facing the ceiling, which is often a more difficult way to deliver. A large episiotomy may be required.This position occurs more often in women who are having their first baby and women who have a narrow midpelvis. • OP- may lead to dysfunctional labour (in primigravida). Contraction may be painful and accompanied by backache
Management of malposition
signs of obstruction/ fetal heart rate is abnormal (less than 100 or more than 180 beats per minute) at any stage If no sign of obstruction Cervix is not fully dilated If cervix is fully dilated caesarean section. BUT no descent in expulsive phase Augmented labour with oxytocin If fetal head is palpable per abdomen 3/5 – 1/5 <1/5 >3/5 Vacuum extraction/ forceps Vacuum extraction/ symphysiotomy
MALPRESENTATION Types: • Breech 3 in 100 • Face 1 in 500 • Brow 1 in 2000 • Shoulder 1 in 300 • Compound
Related Factors: • The woman has had more than one pregnancy • There is more than one fetus in the uterus • The uterus has too much or too little amniotic fluid • The uterus is not normal in shape or has abnormal growths, such as fibroids • Placenta previa • The baby is preterm
Breech Presentation Perinatal mortality up to 4 times compared to vertex presentation. Breech presentation only becomes significant after 36weeks Types of Breech Presentation: • Complete (Flexed) Breech Presentation • Footling Breech Presentation • Frank (Extended) Breech Presentation • Kneeling Breech Presentation
Predisposing factors: • Fetal Prematurity Fetal abnormality Intrauterine death • Placental Placenta praevia Placental cornual • Amniotic fluid Polyhydramnios • Uterine/ pelvic Bicornuate/ septate Pelvic masses
BREECH PRESENTATION-- Management After 36 weeks External cephalic version Spontaneous version
BREECH PRESENTATION-- External Cephalic Version • Attempt external cephalic version if: • Breech presentation is present at or after 36 weeks • Vaginal delivery is possible; • Membranes are intact and amniotic fluid is adequate; • There are no complications (e.g. fetal growth restriction, uterine bleeding, previous caesarean delivery, fetal abnormalities, twin pregnancy, hypertension, fetal death).
BREECH PRESENTATION-- External Cephalic Version • Risks: • Placental abruption • Premature rupture of the membranes • Cord accident • Transplacental haemorrhage • Fetal bradycardia
Absolute contraindication: Previous scar on the uterus Placenta praevia Unexplained APH Pre-eclampsia Multiple pregnancy Relative contraindications: Rhesus isoimmunisation Elderly primigravida IUGR Oligo/ polyhydramnios BREECH PRESENTATION-- External Cephalic Version
Principle: ‘Masterly inactivity • The following points are important for the safe conduct of a breech delivery: • Don’t be in hurry. • Never pull from below and let the mother expel the fetus by her own effort with uterine contractions • Always keep the fetus with its back anterior • Keep a pair of obstetrics forceps ready should it become necessary to assist the aftercoming head • Anesthetist and pediatrician should attend the delivery • Inform the operation theater, if C/S is needed.
BREECH PRESENTATION-- Vaginal Breech Delivery • Await for spontaneous labour • A vaginal examination is done not only to assess the progress of labour • If the membranes rupture, do a vaginal examination immediately to exclude uterine cord prolapse. • If the membranes not rupture, examine for cord presentation. • Do not rupture the membranes • Examine and monitor the woman regularly and adhere strictly to the partogram. • Poor progress may occur if sacrum is posterior/ bigger baby than expected • If there is any delay, the fetus is best delivered by an emergency caesarean section.
BREECH PRESENTATION-- Vaginal Breech Delivery • Delivery of the buttocks • Occur naturally • Delivery of the legs and lower body • Legs flexed : spontaneous delivery • Legs extended : ‘Pinard’s manoeuvre’ • Delivery of the shoulders • Loveset’s manoeuvre • Delivery of the head • Burns Marshall method • Mariceau-Smellie-Veit manoeuvre • Forceps delicery of the aftercoming head
Pinard’s manoeuvre • In breech with extended legs • once the groin is visible gentle pressure can be applied to abduct the thigh and reach the knee. • The knee can be flexed with pressure in the poplitealfossa and the leg delivered. • Anterior leg is always delivered first.
BREECH PRESENTATION-- Vaginal Breech Delivery Loveset’s manoeuvre • This procedure automatically corrects any upward displacement of arms. • In Lovset’s maneuver baby’s trunk is made to rotate with downward traction holding the baby at the iliac crest so that posterior shoulder comes below symphysis pubis and the arm is delivered by flexing the shoulder followed by hooking at the elbow and flexing it followed by bringing down the forearm ‘like a hand shake’. • The same procedure is repeated by reverse rotation of 180 degree so that anterior shoulder comes below the symphysis pubis.
Burns Marshall method • For delivery of the aftercominghead • It is commonly practice where the baby is allowed to hang for a minute or so, • The assistant gives a suprapubic downward and pressure (Kristellar’s maneuver) to promote the head. • Once the nape of the neck is visible, identified by the hairline, the baby’s trunk is gently lifted and swung toward mother’s abdomen holding the baby just above the ankle through an arc of 180 degree. • Left hand guards and slips the perineum over fetal mouth. • As the mouth is born air passage is cleared of mucus and now depressing the trunk the head is allowed to born.
Burns Marshall Method:
Mariceau-Smellie-Veit Manoeuvre Jaw flexion and shoulder traction—JFST(Mariceau-Smellie-VeitManoeuvre) • Here the baby is allowed to rest on the left supinated forearm of the obstetrition, with the limbs hanging on either side. • Left index and middle finger is placed on the malar bones, while the right index and ring fingers are placed on the respective shoulders and the middle finger on the sub-occipital region. • To achieve flexion, traction is now given in downward and backward direction and simultaneous suprapubic pressure is maintained by the assitant until the nape of the neck is visible. • Thereafter, the baby is pulled in upward and forward direction so that the face is born and by depressing the trunk the head is born.
Forceps delicery of the aftercominghead • The long Das/Simpson’s obstetric forceps can be used instead of Piper’s forceps. • The important prerequisite is that head must be in the pelvic cavity and the occiput is directly anterior, i.e. the face is facing the posterior pelvic wall. • Baby is lifted up by the assistant without deviating the trunk to any side and forceps is applied from ventral side.
BREECH PRESENTATION-- Management After 36 weeks External cephalic version Spontaneous version has not occured unsuccessful Follow-ups antenatally until 38 weeks Caesarean section Vaginal breech delivery
BREECH PRESENTATION-- Caesarean Section • Factors that favour: • EBW > 3.5 Kg • Small pelvis (anterior posterior inlet or outlet diameter of less than 11cm ) • Preterm fetus • Footling/ flexed breech • Hyperextended head • Patient with poor obstetric history • complications in the present pregnancy such as pre-eclampsia, intrauterine growth restriction, diabetes, cardiac disease, previous caesarean section
BREECH PRESENTATION-- Caesarean Section • However in 2000 the result of the Canadian Term Breech Trial were published. It came out overwhelmingly with the conclusion that singleton breech presentations at term should preferably be delivered by caesarean section. • Not to do so would invite unacceptable fetal morbidity or mortality. • There is therefore now a trend to deliver all breeches at term by caesarean section.
be remembered however, the results of the study do not apply to • twin pregnancy with breech presentations, • preterm breech deliveries • breech presentations that arrive late • in advanced labour. • In those situations there still appears to be a role for delivering the baby vaginally.
Face Presentation - head is hyper extended - presenting part is face - denominator is chin (mentum) - between glabella & chin - presenting diameter is submentobregmatic (9.5cm) • AETIOLOGY
FACE PRESENTATION-- Diagnosis • Is caused by hyperextension of the fetal head so that neither the occiput nor the sinciput are palpable on vaginal examination. • On abdominal examination, a groove may be felt between the occiput and the back. • On vaginal examination, the face is palpated, the examiner’s finger enters the mouth easily and the bony jaws are felt.
FACE PRESENTATION-- Diagnosis • The chin serves as the reference point in describing the position of the head. • It is necessary to distinguish only chin-anterior positions in which the chin is anterior in relation to the maternal pelvis from chin-posterior positions.
FACE PRESENTATION-- Management • Prolonged labour is common. • Descent and delivery of the head by flexion may occur in the chin-anterior position. • In the chin-posterior position, however, the fully extended head is blocked by the sacrum. This prevents descent and labour is arrested→ caesarean section
FACE PRESENTATION-- Management of Chin-anterior Cervix fully dilated Cervix not fully dilated Allow normal child birth Augmentation of labour Slow progress with no signs of obstruction Descent unsatisfactory Augmentation of labour Forceps delivery
Brow Presentation • The brow presentation is caused by partial extension of the fetal head so that the occiput is higher than the sinciput. • MGT: If the fetus is alive or dead, deliver by caesarean section. *Do NOT deliver brow presentation by vacuum extraction, outlet forceps or symphysiotomy. Mentovertical D = 14cm Attitude = Partial Extension
Shoulder Presentation • Occurs as a result of transverse lie or oblique lie • Predisposing factors = breech presentation • On abdominal examination, neither the head nor thebuttocks can be felt at the symphysis pubis and the headis usually felt in the flank. • On vaginal examination, a shoulder may be felt, but not always. An arm may prolapse and the elbow, arm or hand may be felt in the vagina. • Ultrasound examination
Management • Monitor for signs of cord prolapse. If the cord prolapses and delivery is not imminent, deliver by caesarean section. • In modern practice, persistent transverse lie in labour is delivered by caesarean section whether the fetus is alive or dead.
Compound Presentation • Occurs when an arm prolapses alongside the presenting part. Both the prolapsed arm and the fetal head present in the pelvis simultaneously.
Management • Replacement of the prolapsed arm • Assist the woman to assume the knee-chest position • Push the arm above the pelvic brim and hold it there until a contraction pushes the head into the pelvis. • Proceed with management for normal childbirth • If the procedure fails or if the cord prolapses, deliver by caesarean section
SUMMARY
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