Mal presentation , Mal
Presented by:Dr. Alwaleed M.Alfaki
Gya. & Obs.
Occipto-Posterior Position :-
It is a vertex presentation in which the occiput is
placed posteriorly . It can be:-
1.Right occipto-posterior (the commonest)
In 20% of cases the occipt is posterior at the
beginning of labour .
1. Pelvic Factors:- 50% of cases are associated with
anthropoid pelvis or android pelvis .
2.Fetal Factors:- Marked deflection of the fetal head
due to high pelvic inclination or anterior wall
3.Uterine Factor:- Abnormal uterine contraction
which may be the cause or effect .
Features suggesting the diagnosis include
-backache during labour
-flattening of the abdomen below the umbilicus .
-the fetal limbs are more easily felt near the midline
on both side .
-The head in un engaged and feel larger than usual
vaginal examination :-
-Elongated bag of membrane which is likely to
rupture early .
-High deflexed head with the anterior fontanelle in
the centre of the pelvis .
* First and second stage of labour usually prolonged .
-membrane usually rupture early with the hazards of
cord prolapse and infection .
-In favorable circumstances (90% of cases) good uterine
contraction result in good flexion of the head and the
occipt rotates 3/8 of the circle (135c0
) anteriorly and
deliver as occipto anterior position .
In un favorable circumstances (10% of cases) the occipt
1. Fail to rotate and remain in the oblique
diameter of the pelvis .
2. Rotate anteriorly 1/8th
of circle (short rotation)
and the head become arrested in the
transverse diameter of the pelvis (deep
transverse arrest) .
3. Rotate posterioly 1/8th
of the circle to lie on the
sacral hollow this called direct-occipto-
posterior position . And if the fetus is small &
pelvis is Adequate spontenous delivery can
occur as face to pubic .
- Unless there is fetal hypoxia or other
complication labour is allowed to proceed with the
following special instructions .
-Provide adequate analgesia (an epidural is ideal.
-Prevent dehydration with intravenous fluid
-You may need to promote uterine contraction with
-Good monitoring for progress of labour ,fetal
condition and maternal condition .
- In the majority of cases anterior rotation of the
occipt is completed and the baby is delivered as
- In direct occipto-posterior delivery as face to
pubis may occur ,The perineum should be
protected by a generous episiotomy .
Persistent –occipto posterior and deep transverse
- If the fetal head is not engaged caesarian section
is the treatment of choice .
- If the fetal head is engaged the treatment will be
one of the following .
1) Manual rotation and delivery by forceps as
2) Rotation to occipto-anterior and extraction
using kielland’s forceps .
3) Ventouse (vacuum extraction).
4) Caesarean section if the above lines of
treatment fail or there is other complicating
5) Craniotomy when the fetus is dead .
- The head is completely extended so that the
occipt is in contact with the back .
- The denominator is the mentum (chin) with 4
main position recognized . (Rt) and left mento
anterion and Rt and left mento-posterior .
- Incidence is about 1in 500births .
- In many cases there is no obvious cause
- Anencephaly (10%)
- prematurity (25%)
- multiple pregnancy.
- loops of cord around the neck and a swelling in
the neck such as goitre or cystic hygroma .
-On abdominal examination there is
depression between the anterior
shoulder and the head prominence .
-The fetal heart sounds are heard best
on the same side as the limbs .
-Vaginally the mouth ,nose and orbits
can be felt.
- Most menoanterior positions deliver spontaneously
or by a low forceps.
-mento-posterior cannot deliver vaginally but around
half will rotate spontaneously .
-So mento-posterior should be managed expectantly.
-A persistent mento posterior requires rotation either
manually or by kielland’s forceps ,&then
extraction or very commonly caesarean section.
- The head lies in between full flexion and full
- Incidence about 1:1000 births .
- Causes are the same like face presentation .
On P.V the supra –orbital ridges and anterior
fontanelle are palpable but not the nose ,mouth
or chin .
- In early labour brow presentation may flex to
become a vertex or extend further to a face
presentation both are potentially deliverable
- If the brow presentation persists into or is
discovered in established labour ,delivery
should be by caesarean section .
-Occurs when the long axis of the fetus crosses that of
the mother with the head on one side and breech on
the opposite side of the midline .
-Incidence 1in200briths .
- Multiparity –prematuarity - multiple pregnancy -
poly hydramnios -placenta previa-pelvic tumor
congential malformation of the uterus-IUFD.
contracted pelvis .
- The uterus is broad and asymmetrical .
-The fundal hight is less than date.
-The fetal head is on one side and the breech in the
- Pelvic inlet feels empty but during labour may
be occupied by the shoulder .
- On vaginal examination the presenting part is
high and difficult to define .
- The membrane rupture early in labour and the
cord may prolapse .
During labour the shoulder is Identified by palpating
the following parts acromion process, the
scapula ,the clavicle and axilla ,feeling of the ribs
and intercostal spaces ,on occasion the arm is
found prolapse .
The first line of management is exclusion of a
specific cause . External version followed by
rupture pf membranes and oxytocin infusion is
used by some .However unless there is rabid and
easy correction ,caesarean section should be
- One or more limbs present with the
head or the breech . most commonly
a hand with the vertex .
- The commonest cause is prematurity ,
others are contracted pelvis , pelvic
tumour , poly hydramnios and dead
-The main complcation is prolapse of
the cord .