Jsbsbd Ss Dndjd D Did D Djjddnx d Dm

1. Malpresentations & Malpositions
By: Abdulrahman Hussein Karaki
Supervisors: Dr. Osama Alhasany
Dr. Thana’ Abu Fara

2. Referances:
•Kaplan 2021
•2017 Obstetrics by ten teachers 20th ed
•ALSO 2017

3. Outline:
1. Introduction.
2. Diagnosis.
3. Normal position and presentation.
4. OP Position.
5. Face Presentation.
6. Brow Presentation.
7. Breech Presentation.
8. Other fetal malpresentations.

4. Introduction
• ORIENTATION (Lie): Relation between the long axis of the fetus to the long axis of the uterus.
1. Longitudinal: fetus and mother in same vertical axis.
2. Transverse: fetus at right angle to mother.
3. Oblique: fetus at 45° angle to mother.

5. Introduction
• Presentation: Portion of the fetus overlying the pelvic inlet.
1. Cephalic: head presents first.
2. Breech: feet or buttocks present first.
3. Shoulder: presents first.
4. Compound: more than one anatomic part is presenting.
Cephalic Breech Shoulder Compound

6. Introduction

7. Introduction

8. Introduction
• Position: Relationship of a definite presenting fetal part to the maternal bony pelvis.
1. Occiput: with a flexed head (cephalic presentation).
2. Sacrum: with a breech presentation.
3. Mentum (chin): with an extended head (face presentation).

9. Introduction
• Station: Degree of descent of
the presenting part through
the birth canal; expressed in
centimeters above or below
the maternal ischial spine.

10. Introduction
• Attitude: Degree of extension-flexion of the fetal head with cephalic presentation.
1. Vertex: head is maximally flexed.
2. Military: head is partially flexed.
3. Brow: head is partially extended.
4. Face: head is maximally extended.

11. Introduction
• Diameters:
1. Suboccipito-bregmatic (9.5cm): Vertex.
2. Occipito-frontal (11.5cm): Military.
3. Occipito-mental (13cm): Brow.
4. Subhmento-bregmatic (9.5cm): Face.

12. Introduction

14. Diagnosis
• Leopold’s Maneuvers (abdominal palpation).
• Vaginal examination.
• Imaging: ultrasound.

15. Normal
• ORIENTATION (Lie): Longitudinal.
• Presentation: Cephalic.
• Position: Occiput anterior.
• Attitude: Vertex.
• Diameter: Suboccipito-bregmatic.

16. OP Position
• The fetus lies with its occiput toward the woman’s
spine and its face toward the woman’s symphysis
and abdomen.
• The exact cause of persistent OP positioning is
unknown, but transverse narrowing of the pelvis
plays a role.
• All OP fetuses are somewhat deflexed because the
vertex drops back to fill the hollow of the sacrum.

17. OP Position
• Diagnosis: (difficult)
Back pain, or back labor (hallmark).
Examination.
 Palpation of the anterior fontanel.
Ultrasound.

18. OP Position
• Labor is often prolonged and there is an increased incidence of operative vaginal
delivery, cesarean delivery, and anal sphincter lacerations.
• Mode of Delivery:
1) Spontaneous Delivery (45%).
2) Manual Rotation:
a. Flex the fetal head placing a hand in the posterior pelvis behind the occiput.
b. Apply rotatory force, the rotation should be attempted at the same time as a contraction.
3) Operative vaginal delivery:
 OP is not itself an indication for operative vaginal delivery.

19. Face Presentation
• The head is hyperextended so the occiput is in contact with the fetal back.
• 1 in 500 labours.
• Presenting part: Face.
• Diameter: Subhmento-bregmatic (9.5cm).
• Risk factors:
 Fetus is large or the pelvis is contracted.
 Enlargement of the neck.
 coils of cord around the neck
 Anencephalic

20. Face Presentation
• Diagnosis: vaginal examination.
• The mouth, nose, and the malar prominences may be palpated.
• Mode of Delivery:
The fetus must rotate to a mentum anterior position → Spontaneous vaginal delivery / Forceps
Persistent mentum posterior → cesarean delivery.
Vacuum extractor is absolutely contraindicated.

21. Brow Presentation
• The portion of the fetal head between the orbital ridge and the anterior
fontanel presents at the pelvic inlet.
• occurring in 1 in 2,000 labours
• Diameter: Occipito-mental (13cm).
• Diagnosis: vaginal examination.
• The frontal sutures, anterior fontanel, orbital ridges, eyes, and root of the nose may
be felt.
• Mode of Delivery:
 If it converts to vertex or face → according to their respective mechanisms.
 Persistent brow → cesarean delivery.

22. Breech Presentation
• Most commonly encountered malpresentation and occurs in 3–4% of
term pregnancies, but is more common at earlier gestations.
• Types:
Frank/Extended:
 thighs flexed
 legs extended
Complete/Flexed:
 thighs and legs flexed
Footling/Incomplete:
 thighs and knees extended
 foot presents at the cervix

23. Breech Presentation
• Predisposing factors:
Fetal/placental
 Multiple gestation.
 Prematurity.
 Placenta previa.
 Abnormality (e.g. anencephaly or hydrocephalus).
 Fetal neuromuscular condition.
 Oligohydramnios.
 Polyhydramnios.:
Maternal:
Fibroids.
Congenital uterine abnormalities
(e.g. bicornuate uterus).
Uterine surgery.

24. Breech Presentation
• Prenatal Management:
• If a breech presentation is clinically suspected at or after 36 weeks:
 Fetal biometry
 Amniotic fluid volume
 Placental site
 Position of the fetal legs
 Any anomalies previously undetected
• Mode of Delivery:
1) Elective caesarean section (best method)
2) External cephalic version (ECV)
3) Vaginal breech delivery

25. Breech Presentation
• External cephalic version:
• procedure is performed at or after 37 completed weeks’ gestation.
• Performed with a tocolytic (e.g. nifedipine).
• Success rates 50% (experience, multiparous women).
• Mildly uncomfortable for the mother.
• Should last no more than 10 mints.
• A fetal heart rate trace must be performed before and after the procedure.
• Rh- → anti-D.

26. Breech Presentation
• External cephalic version: (Contraindications)
• Fetal abnormality (e.g. hydrocephalus).
• Placenta previa.
• Oligohydramnios or polyhydramnios.
• History of antepartum hemorrhage.
• Previous caesarean or myomectomy scar on the uterus.
• Multiple gestation.
• Pre-eclampsia or hypertension.
• Plan to deliver by caesarean section anyway.

27. Breech Presentation
• External cephalic version: (Complications)
• Placental abruption.
• Premature rupture of the membranes.
• Cord accident.
• Transplacental hemorrhage.
• Fetal bradycardia or decelerations, usually transient and self‐limited

28. Breech Presentation
• External cephalic version: (Technique)
Elevate breech with
suprapubic hand
Push breech into iliac fossa
while flexes fetal head

29. Breech Presentation
• External cephalic version: (Technique)
fetus becomes
transverse lie
The fetal heart rate should be
checked after the external
version has been completed

30. Breech Presentation
• Vaginal breech delivery: (Pre-requisites)
• The presentation should be either extended/frank or flexed/complete (but feet not below the
fetal buttocks).
• No evidence of feto-pelvic disproportion.
• Estimated fetal weight of <3,500 g.
• No evidence of hyperextension of the fetal head.
• No fetal abnormalities (e.g. severe hydrocephalus).
• Operating room accessibility (for urgent cesarean delivery).

31. Breech Presentation
• Vaginal breech delivery: (Technique)
1) Delivery of the buttocks:
Deliver spontaneously
2) Delivery of the legs and lower body:
Pinard’s maneuver

32. Breech Presentation
• Vaginal breech delivery:
(Technique)
3) Delivery of the shoulders:
Loveset’s maneuver.

33. Breech Presentation
• Vaginal breech delivery:
(Technique)
4) Delivery of the head:
Modified Mauriceau‐
Smellie‐Veit (MSV) Maneuver

34. Breech Presentation
• Vaginal breech delivery: (Complications)
• Nuchal arm(s)
• Head entrapment
• Umbilical cord prolapse

35. Other fetal malpresentations
• Transverse Lie or Shoulder Presentation: (Causes)
• Unusual relaxation of the abdominal wall
• Preterm fetus
• Placenta previa
• Abnormal uterus
• Contracted pelvis
• Tumor occluding the birth canal
• Polyhydramnios

36. Other fetal malpresentations
• Transverse Lie or Shoulder Presentation:
• Incidence: occurring in 1 in 300 pregnancies.
• Diagnosis: Vaginal examination.
• Mode of Delivery:
• Spontaneous birth in transverse lie is impossible.
• Cesarean delivery is mandatory in most cases.
• Before the onset of labor or in early labor with intact membranes → attempt ECV.

37. Other fetal malpresentations
• Compound Presentation:
• Often no cause is found.
• More common with premature infants.
• Diagnosis: Vaginal examination.
• Mode of Delivery:
• Most commonly the prolapsed limb will deliver spontaneously along with the head, or sometimes the
fetus will retract its limb spontaneously.
• If the prolapsed arm appears to be impeding descent, it should be gently elevated upward.
• Occasionally cesarean delivery will be necessary.