Unergraduate course lectuers in Obstetrics&Gynecology,Faculty of medicine,Zagazig University Prepared by Dr Manal Behery

2. Definition
Defintion
Fetal presenting part other than
vertex includes breech, face,
brow, transverse, and compound
presention.

3. Related Factors
More than one pregnancy
(e.g. Multipara,Grand multipara )
More than one fetus (e.g. Twins)
Too much or too little amniotic fluid (e.g.
Poly hydramnious, oligohydramnios)
Abnormal uterine shape (e.g. Arcuate
,septate, supseptate) or abnormal growth
(e.g Fibroid)
Placenta previa
The baby is preterm

4. Incidence of malpresentation
Defintion
• Breech 3 in 100 (3%)
• Face 1 in 500 (0.5%)
• Brow 1 in 2000 (0.02%)
• Shoulder 1 in 300 (0.3%)
• Compound 1 in 5000 ( 0.05%)

6. Shoulder presentation
It is a Transverse lie
in which the long axis of the
fetus is perpendicular( 900)
to long axis of mother.
Shoulder of baby comes in
– the lower segment of uterus(0.5%)

7. 4 position in Shoulder presentation
 Acrimon- anterior(60%)
 Left
 Right
 Acrimo- posterior(40%)
 Right
 Left
 Acrimo anterior position is more common as the
concavity of front of fetus fix in convexity of
maternal spine
 Placenta is posterior in 60% of cases

8. Lt Acrimoanterior Rt Acrimoanterior
Rt Acrimoposterior Lt Acrimoposterior

9. Diagnosis
Abdominal examination,
 the head is usually felt in one
iliac fossa or in the flank.
 The breech in the other iliac
fossa but at a higher level
 Fundal level just above
umbilicus
 FH sound heard below the
umbilicus

10. On vaginal examination
Early in labor
 the cervix is elevated
 lower uterine segment is
imperfectly filled
Late in labor
 The cervix is sufficiently dilated: We can feel:
scapula, acromion, clavicle, axilla and ribs
Confirm position: If the arm is prolapsed
and supinated the dorsum points to the
back and the thumb points to the head.

11. Neglected shoulder
Prolonged labor
Membrane ruptured
liquor drained
Arm may be prolapsed
Fetus dead or dying
Lower segment overstretched
Signs and symptoms of obstructed labor

12. Management
During pregnancy
 A-External cephalic version
 Can be tried up to full term,
 Even early in labour before ROM
 * Laxity of the abdominal & uterine walls
makes the procedure easier than in breech
 * The fetus will be rotated only 90 degrees.
 B. If fails, do external podalic version.
head.

13. During labor
 External cephalic version (ECV) is tried with
intact membranes :
 - If succeeded:
Rupture of membranes and application of
abdominal binder.
 - If failed:
C.S. is the safest for the mother & fetus.
 If the membranes are ruptured before full
cervical dilatations do C.S.

14. Management
In modern practice, persistent
transverse lie in labor is delivered by
caesarean section whether the fetus is
alive or dead

16. Face Presentation
head is hyper extended
presenting part is face
- denominator is chin(mentum)
between glabella & chin
presenting diameter is
submentobregmatic (9.5cm)

17. Types of Face Presentation
2ry face (during labor) commen
The majority of cases of face are
secondary to occipto-posterior which
transformed to mento anterior
Causes are maternal
1ry face (during pregnancy )rare
Causes are fetal

18. AETIOLOGY

19. In Face presentation- 6 position

20. Lt mento-ant Rt mento-ant Rt mento-post

21. Diagnosis
 The chin serves as the
referenc point in describing
the position of the head.
 It is necessary to distinguish
chin-anterior positions in
which the chin is anterior in
relation to the maternal pelvis
from chin-posterior positions.

22. Diagnosis
 On abdominal examination,
a groove may be felt between
the occiput and the back.
 On vaginal examination
 Neither the occiput nor the
sinciput are palpable
 supra-orbital ridges, chin,
alveolar margin ± ala nasi
Confirm presention

23. Mechanism of labor in MA
 The head descends with the submento-bregmatic
diameter (9.5 cm).
 Descent, engagement, increased extension of
the head
 the chin meets the pelvic floor first and rotates
forwards 1/8 of a circle.
 With further descent the submental-region
hinges below the symphysis pubis
 the head is delivered by flexion , followed by
restitution and external rotation of the chin as in
vertex presentation.

24. Mechanism of labor in MP
 Normal mechanism: In 2/3 of cases
 the chin rotates forwards 3/8 of a circle
 and delivered as MA
 Abnormal mechanism (In 1/3 of cases):
 The chin may rotate forwards
 1/8 circle (deep transverse arrest of the face).
 no rotation(persistent oblique MP).
 The chin rotate backwards 1/8 circle (direct MP)

25. Management of Chin-anterior
Management of Chin-anterior
Cervix fully
dilated Cervix not fully
dilated
Allow normal child
Allow normal child
birth Augmentation of
Augmentation of
birth
Slow
Slow labour
labour
progress
progress Descent
Descent
with no
with no unsatisfactory
unsatisfactory
signs of
signs of
obstruction Augmentation
obstruction Augmentation Forceps delivery
of labour
of labour

27. It is a cephalic presentation with the
head midway between flexion and
extension.
Incidence: 1 /2000
The frontal bone is
the denominator.

28. There are 4 main positions
• - Left fronto-anterior.
• - Right fronto-anterior.
• - Right fronto-posterior.
• - Left fronto-posterior.

29. Types &Etiology of brow
Transient brow(2RY)
• During conversion of vertex to face.
Persistent brow(1RY)
• Extremely rare
Etiology: same as face

30. Mechanism of labour
Transient brow(2RY)
brow may be converted spontaneously into
face (by extension) or vertex (by flexion)
and this followed by spontaneous delivery

31. Persistent brow:
There is no mechanism
for delivery because the
head descends by the mento
-vertical diameter (13.5 cm)
which is longer than any
of the diameters of the pelvic inlet.
 So, the head become arrested at the
pelvic inlet ,and labour is obstructed.

32. Diagnosis
Abdominal examination:
the occiput & sinciput
are felt at the same level
PV examination
frontal bone, supra-orbital
ridges and the root of the
nose are felt.

33. Compound Presentation
Occurs when an extremity
(usually an arm less
commonly lower limb)
prolepses alongside the
presenting part.
• Both the prolapsed arm and
the fetal head present in the
pelvis simultaneously.

34. Diagnosis
Suspect compound presentation
when
1.Active labor is arrested
2.The fetus fail to engage
3.The prolapsed extremity is palpated
directly

35. Management
Don’t manipulate the prolapsed extremity
 In many cases the extremity will spontaneously
be pulled back and away from the presenting
part.
 Spontaneous delivery in 75% of vertex /upper
extremity presentation
 Do continuous FHR monitoring because of
associated occult cord prolapse

36. Reduce the extremity if
 Prolapsed extremity prevent descent of
fetus gently reduce by pushing it upward
above the pelvic brim and hold it until a
contraction pushes the head into the pelvis.
Do CS if
 Non reassuring FHR trace
 Cord prolapsed
 Failure of labor to progress

37. THANK YOU