malpositions and management

1. ⚫An abnormal position of the vertex rather than an
abnormal presentation.
⚫In a vertex presentation when occiput is placed
posteriorly over the sacro -illiac joint or directly over
sacrum, it is called occipito -posteriorposition.

3. sacro-illiac
position of
⚫When the occiput is placed over right
joint , Right occipito-posterior(ROP)/3RD
vertex.
⚫When the occiput is placed over left sacroilliac joint,
Left occipito -posterior(LOP).also called 4th position of
vertex.
⚫ when it points towards sacrum, is called Direct
occipito-posterior .

5. INCIDENCE
⚫At the onset of labour ,the incidence of O-P is about
10% & is much less in latesecond stageof labour.
& dextro-
⚫ ROP is 5 times morecommon than LOP
⚫Presence of sigmoid colon on the left
rotationof the uterus favours ROP.

7. CAUSES
⚫MATERNAL-
shapeof inlet- Anthropoid/android pelvis
more than 50% cases because the wide occiput can be
comfortablyplaced in widerposteriorsegmentof pelvis.

9. ⚫FETAL-Marked deflection of head favours posterior
position. Itoccursdue to
 High pelvic inclination.
 placenta previa
 pelvic tumours
 Primary brachycephaly
⚫ UTERINE –Abnormal uterinecontraction

10. Diagnosis: –
Inspection :-
- Abdomen looks flat below the umbilicus.
Palpation :-
Fundal height :- correspondswith period of
amenorrhoea.
Fundal grip :- breech.

11. Inspection- infra umbilical flattening

12. Lateral grip :-Foetal back is felton rt. Flank of
mother in ROP & in left flank, in LOP.
Fetal limbs are felt easily as knob like structure
anteriorly.

14. Pelvicgrip :-Head is notengaged.
-Cephalic prominance (sinciput) is not felt so
prominentas found in well flexed occipito –anterior.
-In directoccipito – posterior the small sinciput is
confused with breech.

15. -Auscultation :
FHS is best heard in flank in directoccipito –
posterior / R.O.P.
-but difficult in L.O.P.

16. Vaginal examination :-
1. Finding depends upon degree of flexion of head.
2. Confirmation madeduring 2nd stageof labour:-
a.Sagittal suture:- occupies anyof theobliquediameter
of pelvis.
b. posterior fontanelle :-felt near the sacro-iliac joint.
c. anterior fontanelle :- felt near the ilio-pectineal
eminence.

17.  Sometimes the position is not recognized until there is
delay in thesecond stage of labour.
 The diagnosis by vaginal examination may be difficult due
to the formationof caput succedaneum over the presenting
part.
 In this case the fingers may be passed higherto feel the free
margin of theearwhich will point to theocciput.

18. MECHANISM OF LABOUR
⚫The head engages through right obliquediameter in
ROP & leftobliquediameter in LOP.
⚫The engaging transversediameterof head is biparietal
(9.5cm)
⚫Anterior-posteriordiameter is either
suboccipitofrontal (1ocm) oroccipitofrontal (11.5cm).

19. IN FAVOURABLE CASES(90%)
⚫Good uterinecontraction results in good flexion of
head. normal descentoccurup to pelvic floor.
⚫Occiputrotates 3/8th of a circle(135degree) anteriorly
to lie behind symphysis pubis. shoulders rotateabout
2/8th of circle tooccupyobliquediameter.
⚫Rest of the mechanism is like that of right
occipitoanterior in ROP & left occipitotanterior in
LOP.

20. In favourable case

21. UNFAVOURABLE CASES(10%)
non rotation or malrotation
⚫Certaincases occiput fails to rotate-
 Deflexion of the head
 Weak uterinecontraction
 Flatsacrum
 Prominent ischial spine
 Convergentsidewalls
 Weak pelvic floor muscles
 Big baby
 Earlydrainage of liquor

22. 23

23. ⚫ 3 types results
 Incomplete forward rotation –occiput rotates 1/8th of
circle sagital suture comes to lie in bispinous diameter
results in Deep transverse arrest. It occurs in mild
deflexion of head.
 Nonrotation –both sinciput & occiput reaches pelvic
floor at same time & sagital suture lies in oblique
diameter results in Oblique posterior arrest. It occurs
inmoderate deflexion of head.

24. Malrotation - the sinciput touchespelvic floor first
resulting in anterior rotationof sinciput 1/8th of circle
putting occiput to sacral hollow called Persistent
Occiput -posterior Position of vertex. It occurs in
extreme deflexion. Alsocalled occipito -sacral
position.

25. ⚫In favourable circumstances in persistent
occipitoposterior position, spontaneous delivery
occurs as face to pubis. Descend of head occurs until
root of nose hinges under symphysis pubis. Delivery
of brow, vertex, occiput lastly face is born by
extension .Restitution ,external rotation &delivery of
trunk occurs normally.

26. COURSE OF LABOUR
⚫Avg duration of both 1st& 2nd stage of labour is
increased.
⚫FIRST STAGE-
engagement is delayed
 persistenceof deflexion of head
Driving force transmitted through the fetal axis is
notalignmentwith axis of inlet.

27. Early rupture of membraneoccur.
Abnormal uterinecontraction
SECOND STAGE-delayed due to long internal
rotation or malrotation , with at times, arrest of
head
THIRD STAGE-increased incidence of postpartum
hemorrhage & trauma togenital tract

28. M
 ODE OF DELIVERY
Long anterior rotation of occiput -spontaneous or
assisted vaginal delivery occurs.(90%)
Short posterior rotation-spontaneous or assisted
vaginal delivery may occur as face to pubis. but there is
more chance of perineal tear

29. ⚫Non-rotation or short anterior rotation-spontaneous
vaginal delivery highly unlikely . May progress to
prolonged orobstructed labour.

30. MANAGEMENT OF LABOUR
Earlydiagnosis
Strictvigilance with watchful expectancy hoping for
descent &anteriorrotationof occiput
Judicious & timely interference if needed
Earlycaeserean section

31. Management of the first stage of labour:
The 1st stage is managed as in a normal case.
Nothing can bedone tocorrect the Malposition or to
influence the rotation of the head at this stage.
A partogram is done to monitorthe :
1.Uterinecontraction (frequency, duration and strength
).
2.Fetal heart.
3.Dilatation of the cervix.

32. If progressive cervical dilatation does not occur
augmentation with an oxytocin drip may be tried.
If still no progress obtained in a few hours
caesarian section (C/S) is performed.
Also if there is fetal distress C/S is done

33. Management of the 2nd stage of labour:
1.In most cases (70% ) provided that the uterinecontractions
are strong and the woman is able to make good expulsive
efforts the occiput rotates forward and normal delivery
takes place.
2.In othercases (10% ) the baby may bedelivered face-to-
pubes with out difficulty but there is a great risk of a
perineal tear.

34. ⚫3.In about 20% of cases there is failure of the
presenting part to rotate and descend and such
cases delivered by C/S or rotation can be enhanced
byassistance .

35. Fate of OPP
OPP
Engaging diameter :- occipito-
frontal 11.5cm orsub-occipitofrontal
10cm.
Favorable (90%)
Unfavorable (10%)
3/8th rotation
occiput comes under
symphysis pubis (rt/lt
occipitoanterior)
Normal vaginal delivery
Mild deflexion Severe deflexion
Moderatedeflexion
Occiput rotate by
1/8th circle
Deep
transverse
arrest
Non-rotation
Oblique
posterior
arrest
Occiput rotate
posteriorly by 1/8th
POPP/ occipito-
sacral position
Face to pubis
delivery
Arrest

36. Arrest In occipito-transverse or
oblique position
Ventose
It is suitable in cases where the pelvis is
adequete & non-rotation of the occiput due to
weak contraction or lack of toneof pelvic floor.
.

37. Alternative methods-
Manual rotation followed by forceps extraction
Forceps rotation & extraction
Caesarean section
craniotomy

38. Manual rotation & forcep extraction
⚫First head is rotated manually till the occiput is
placed behind symphysis . It is donewith either by
whole hand method or half hand method. Then
forceps bladesareapplied.
The pelvisshould beadequate,
Baby is of average size
There is good amountof liquor

39. Full hand method

40.  Should bedone underpudendal block or
general anaesthesia.
 The head is rotated with the fingers toa direct
anterior position.
Contd…

41. Contd…
 The shoulder girdle of the fetus should be rotated
at the same time as the head by pressure through
the abdominal wall byexternal hand.
 After rotation completed an obstetric forceps are
applied tocomplete the delivery.

42. Difficulties duringmanualrotationare-
Failure togrip head adequatelydue to lack of space.
Failure todislodge head from impacted position
Inadequate anaesthesia
Wrong caseselection
Complications-
Accidental slippageof head
Prolapse of cord

43. Forceps rotation&extraction
It is done byexperts
 Kielland’s forceps used.
Advantagesover manual rotation
Nochanceof displacementof head
Noaccidental cord prolapse
Rotationcan bedoneaboveor below the level of
obstruction

44. Caeserean section-
Done if there is mid pelviccontraction, I t is much safer
than rotation
Craniotomy
- it is done in casesof dead baby

45. Occipito sacral arrest
⚫Below the
spine
Station of head
Above the
level of ischial
spine
C/S
Ventouse or
forceps with
deep
episiotomy

46. Deep transverse arrest:
Means arrest of labour when the fetal head has
descended to the level of the ischial spines and the
sagittal suture lies in the transverse diameter of
the pelvis.
The occiput lies on one side of the pelvis and the
sinciput on the other side and the head is badly
flexed.

47. It is only diagnosed during the 2nd stage of labour.
If the head is firmly fixed in the transverse
position obstructed labourwill occur

48. Management of DTA
DTA or oblique posterior arrest
Assisteddelivery
Pelvis adequate Inadequate pelvis
-Manual rotation of occiput to
anteriorposition followed by forceps
extraction
- vacuum delivery
- forcepsrotation
Dead baby
Craniotomy
C/S