The document discusses malpresentations in childbirth, defining various types such as breech, face, brow, and shoulder presentations, as well as their complications for both mother and fetus. It outlines diagnostic methods, management strategies including vaginal delivery and cesarean options, and factors influencing the likelihood of these presentations. Additionally, it provides details about potential risks and complications associated with each type of malpresentation during labor and delivery.

1. Malpresentations

2. Learning objectives
• Introduction
• Definition of mal presentation
• Diagnosis of mal presentation
• Management of mal presentation
• Complication of mal presentation
2

3. Introduction
• Presentation is defined as:
▪Part of the fetus that directly overlies the pelvic
inlet, or foremost within the birth canal or in closest
proximity to it.
• Any presentation other than vertex are called
Malpresentation.
• Malpresentations include: Face, brow, breech,
shoulder, or compound.
• Malpresentation is often associated with increased
risk to both the mother and the fetus

4. Definition of terms
• Fetal Lie:- is the relation of the long axis of the fetus
to the long axis of the mother
• Attitude:- refers to the position of the fetal head in
relation to the neck.
• Presentation:- refers to the fetal part that directly
overlies the pelvic inlet.
• Position :- refers to the relationship of the fetal
presenting part to the maternal pelvis.
• Station:- is a measure of descent of the bony
presenting part of the fetus through the birth canal

7. Predisposing Factors
Maternal
• Contracted pelvis
• Pendulous abdomen, High
parity
• Pelvic tumors:-
fibromyomas, ovarian
tumor etc.
• Uterine anomalies:-
bicornuate uterus, uterine
septum etc…
Placental and Membranes
• Placenta previa
Fetal
• Prematurity
• Fetal attitude
• Fetal anomaly (e.g.
hydrocephalus,
anencephalus)
• Polyhydramnious /
oligohydramnious
• Multiple pregnancy

8. Complications of malpresentations
Maternal
• Genital trauma
• Post partum
hemorrhage
• Intrapartum
infections
• Puerperal sepsis
• Complications of
operative delivery
Fetal/Neonatal
• Birth trauma- IVH;
Nerve injury (palsy)
• Perinatal asphyxia
• Cord prolapse
• Neonatal infections
• Increased risk of
meconium aspiration
syndrome

9. Complications of malpresentations…
Labor and Delivery
• Prolonged labor
• Obstructed labor
• PROM
• Increased operative vaginal delivery
• Increased caesarean delivery
• Inefficient uterine action

10. Breech presentation
• It is a longitudinal lie in which the buttocks is the
presenting part with or without the lower limbs.
• Diagnosis can be made through abdominal palpation,
vaginal examination and confirmed by ultrasound
Types
• Frank: hip flexed and knee extended commonest
• Complete: hip and knee are flexed, in multipara
• Footling: hip and leg are extended, one /both feet
present,
• Knee: the hips are extended with knees flexed

13. Prematurity, fetal malformation, Uterine anomalies, and polar
placentation are commonly observed causative factors

14. Etiologic factors
• Prematurity : due to small foetal size, relatively
excess amniotic fluid, and more globular shape of
the uterus.
• Multiple pregnancy:
• Poly-and oligohydramnios.
• Hydrocephalus, anencephalus.
• Bicornuate and septate uterus.
• Uterine & pelvic tumors.
• Placenta praevia

15. Recurrence
• Risk of breech presentation in a 2nd pregnancy:
• 2% if the first infant was non breech
• 9% if the first infant was breech and
• After two consecutive breech deliveries, 21 to 28%
• After 3 consecutive breech deliveries the risk is
38%.
• Men or women who were delivered at term from
breech presentation were twice as likely to have
firstborn offspring in breech presentation.
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16. Diagnosis
Abdominal Examination after 34 weeks
• Leopold maneuver:
• The hard, round, readily ballotable fetal head occupy
the fundus.
• FHB will be heard more easily at or above the umbilicus
Vaginal Examination
• Frank breech presentation:
• Ischial tuberosities, sacrum, and the anus ..palpable
• After further fetal descent, the external genitalia may be
distinguished.
• The sacrum are palpated to establish the position and
presentation
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18. May confuse with Face presentation
Breech:
• Finger encounter muscular resistance by
the anus
• Stained with meconium on removal
• Ischial tuberosity and anus are in straight
line
• While mouth and malar eminence form
triangular shape in face.

19. Cont…
Sonography
• The best confirmation of a suspected breech
presentation is with U/S.
• It also can provide information regarding the
breech type and EFW.
Management of Breech Presentation
1.Vaginal delivery
2.Cesarean delivery
3. External cephalic version (ECV) …Antenatally if
spontaneous version is not occurred
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20. Management
Indications for C/S
• large fetus ( EFW ≥3500gm) or < 1.5kg
• Any degree of pelvic contracture
• Footling breech
• Ux dysfunction
• Severe IUGR
• Breech with poor obstetric performance
(previous perinatal death)
• Elderly primigravida
• Others:
▪Request for sterilization
• Zatuchini – Andros score <4

21. If the score is 0-4, cesarean delivery is recommended
decision regarding mode of delivery should depend on the
experience of the health care provider
Zatuchni-Andros Breech Scoring
0 1 2
Parity 0 1 2
Gestational
age (wk)
39+ 38 <37
EFW (lb) 8lb (3.6kg) 7-8 lb(3.2-3.6kg) <7 lb(<3.2kg)
Previous
breech
0 1 2
Dilatation 2 3 4
Station -3 -2 -1

22. Vaginal delivery
Indications
• No fetal indication for c/s
• Wt < 3500gm
• Franck breech
• Adequate pelvis
• Zatuchini – Andros score > 4
• Documented lethal fetal congenital anomalies
• Presentation of mother in advanced labor with
no maternal or fetal distress
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23. Methods of Vaginal Delivery
General methods of vaginal breech delivery:
1. Spontaneous breech delivery: without any
traction or manipulation other than support of the
newborn.
2. Partial breech extraction. The fetus is delivered
spontaneously as far as the umbilicus, but the
remainder of the body is extracted will be assisted
by maneuvers.
3. Total breech extraction. The entire body of the
fetus is extracted by the obstetrician. Replaced by
C/S
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24. Mechanism of labor in breech
Engagement and descent:
• Takes place with the Bitrochanteric Ø 10 cm in one of
the oblique Ø of the Pelvis
Internal rotation
• Ant. hip toward the pubic arch
• Bitrochanteric Ø in Antero-posterior
Lateral flexion
External rotation:
• After birth of the breech
• Back turning anteriorly (SA)
• Shoulder brought into one of the oblique Ø of the
pelvis (biacromial diameter 12 cm)
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25. Assisted vaginal breech delivery
• Instruct the mother to bear down with every
contraction (2nd stage).
• Episiotomy – when fetal anus is visible and
perineum distended unless perineum is well relaxed.
• Allow the breech to be delivered and wait without
intervention till body born up to the level of
umbilicus.
• The golden rule is to "Keep your hands off“ to
deliver the fetal buttock and
• The body is allowed to deliver spontaneously up to
the level of the umbilicus
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27. • After the umbilicus has
been reached, wait
spontaneous delivery of
the legs .
• If not delivered
spontaneously, deliver
one leg at a time:
• Flexion and abduction
of thigh, subsequent
delivery of the lower leg.
• Do not pull the baby
while the legs are being
delivered
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28. Pinard maneuver
• If no spontaneous delivery of the legs
• two fingers are carried up along one extremity to the
knee to push it away from the midline.
• Spontaneous flexion usually follows,
• Exerting pressure laterally to sweep the legs away
from the mid line.
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31. 31
• Following delivery of the
legs, the fetal bony pelvis
is grasped with both
hands, using a cloth
towel moistened with
warm water.
• The fingers should rest
on the anterior superior
iliac crests and the
thumbs on the sacrum,
minimizing the chance of
fetal abdominal soft
tissue injury

32. 32
Lovset’s Maneuver
• Arms are stretched
above the head or
folded around the
neck:
• Gentle downward
traction is combined
with an initial 900
rotation of the fetal
pelvis through one arc
and
• Then a 1800
rotation to
the other, to effect
delivery of the scapulas
and arms

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35. Deliver head by: Mauriceau Smellie Veit maneuver:
35
• Lay the baby face down
with the length of its body
over your hand and arm.
• Place the first and third
fingers of this hand on the
baby’s cheekbones and
place the second finger on
the baby’s chin.
• Use the other hand to
grasp the baby’s shoulders
and to push the occiput

37. Delivery of the head….
• Bern's Marshal maneuver- The baby is allowed to
hang by its own weight with suprapubic pressure &
• Up ward movement of the baby while the other hand
supporting the perineum
37

38. • Piper forceps can be used to
deliver the after coming
head, when MSV maneuver
cannot be accomplished
easily.
• Suspension of the body of
the fetus in a towel
effectively holds the fetus
and helps keep the arms
out of the way
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Forceps to After coming Head

39. Complications of Breech Delivery
A. Maternal:
• Prolonged labor with maternal distress.
• OL
• Laceration especially perineal.
• PPH due to prolonged labor and lacerations.
• Puerperal sepsis
B. Fetal:
• Intracranial haemorrhage (IVH)
• Fracture, dislocation of the cervical spines
• Asphyxia due to: Cord prolapse or compression
• Rupture of an abdominal organ.
• Brachial plexus injury. 39

40. External Cephalic Version(ECV)
• When a breech presentation is recognized prior to
labor in a woman who has reached 36 weeks'
gestation, ECV should be considered.
• Before this time, there is a relatively high incidence
of recurrence.(unstable)
• After 36 weeks, however, the likelihood of
spontaneous version is low.
• Version is C/I if vaginal delivery is not an option
• Anti-D immune globulin is given if indicated.
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41. Factors Associated with Successful Version
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42. Technique of ECV
• ECV should be carried out in an area that has ready
access to a facility equipped to perform emergency
cesarean deliveries.
• U/S examination is performed to confirm non
vertex presentation and adequacy of AFV, to exclude
obvious fetal anomalies if not done previously and
to identify placental location.
• External monitoring is performed to assess fetal
heart rate reactivity.
• Version attempts are discontinued for excessive
discomfort, persistently abnormal fetal heart rate, or
after multiple failed attempts.
42

43. Technique…
• A forward roll of the
fetus usually is
attempted first.
• Each hand grasps one
of the fetal poles, and
• The buttocks are
elevated from the
maternal pelvis and
displaced laterally.
43

44. Technique…
• The buttocks are then
gently guided toward
the fundus, while the
head is directed
toward the pelvis.
• If the forward roll is
unsuccessful, then a
backward flip is
attempted.
44

45. Complications
• Placental abruption,
• Uterine rupture,
• Fetomaternal hemorrhage,
• Isoimmunization,
• PROM
• Preterm labor, fetal compromise, and even death.
• Amniotic fluid embolism.
45

46. Brow Presentation
• It is a cephalic presentation in which the head is
midway between flexion and extension.
• Diagnosed when the portion of the fetal head
between the orbital ridge and the anterior fontanel
presents at the pelvic inlet.
• Presenting diameters in brow presentation:
• Biparietal diameter – 9.5 cms
• Mentovertical diameter- 13.5 cms
• Most brow presentations at term are transitory
presentations in early labor.

48. Diagnosis of Brow Presentation
During pregnancy:
• It is difficult.
• Ultra sonography may be helpful.
During labor:
• Frontal bones,
• Supra-orbital ridges, and
• Root of the nose but not the chin.
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49. Mechanisms of Labor…
Persistent brow:
• The engagement diameter is the mento -vertical 13.5
cm which is longer than any diameter of the inlet
• So there is no mechanism of labor and labor is
obstructed.
Transient brow:
• May occur during conversion of vertex into face
presentation.
• So if brow is flexed to become vertex or extended to
become face it may be delivered.
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50. Management:
Early in the first stage:
1. Observe carefully and given a chance for
spontaneous conversion into either face or vertex.
2. Exclude contracted pelvis, if present do S/C
In the second stage:
If considered as persistent brow so:
1. Caesarean section is done if the foetus is living.
2. Craniotomy if the foetus is dead.
50

51. Face presentation
• It is a cephalic presentation in which the head is
completely extended, allowing the occiput to touch
the back
Boundaries:
• Superiorly; supra orbital ridges and the root of the
nose.
• Inferiorly; the mentum.
• Sub-mento bregmatic: 9.5
• Denominator : mentum

52. Face presentation…
• Possible positions 8 (e.g. MA, left mento transverse..)
• It is presumed to occur because of factors that:
1. Favor extension: goiter and excessive nuchal
cords
2. Prevent flexion of the fetal neck.
• Other factors includes:
▪CPD, Contracted maternal pelvis & platypelloid
pelvis
▪Prematurity/low birth weight, polyhydramnios
▪Macrosomia
▪Multiparity
▪Extreme laxity of the anterior abdominal wall

54. Mechanism of action
• In mento anterior positions, delivery follows by
flexion of the head towards the symphysis pubis
(face to pubis)
• In MA vertex fit into the hollow of the sacrum and
the chin fits under the symphysis.
• Persistent MP positions cannot be delivered
vaginally as the fetal brow pressing over the
symphysis precludes flexion
• Presenting diameter sterno-bregmatic(18cm)
• An open fetal mouth may act as a fulcrum
against the sacrum preventing further descent.

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59. Diagnosis
• In prolonged labor with facial edema, can be DDx
breech presentation on vaginal exam
The distinguishing features from frank breech
1. The mouth and the malar eminences are not in a
line; but the anus and the ischial tuberosities are in
one line,
2. Sucking effect of mouth,
3. Absence of meconium staining on the examination
fingers.
Antenatal diagnosis is rarely made.

61. Management
• Vaginal delivery can be tried in MA and
rotated MP
• Augmentation is controversial
• C/S if persistent MP

62. Shoulder Presentation
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• Shoulder presentation occurs with
the fetus is in the transverse lie.
• May accompanied by a hand
prolapse.
• Diameter attempting to be
delivered in shoulder
presentations is the crown-rump
length
• Possible positions of shoulder
presentation include: dorso
anterior; dorso posterior; dorso
superior and dorso inferior

63. Diagnosis of Shoulder Presentation
• Leopold’s palpations
✔ Transverse lie diagnosed.
✔Abnormal after the 34th
week of pregnancy.
• Vaginal examination
✔In delayed and neglected cases the hand and arm
may prolapse.
✔Cord prolapse rate is the highest among the
malpresentations (20%).
• Sonography
✔In addition to confirming the diagnosis, presence of
congenital anomalies, placenta previa, uterine
anomalies and fetal size assessment should be made.
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65. Management
• In rare circumstances when the fetus is very small
and the pelvis is capacious, a shoulder presenting
fetus can be delivered doubled up
• “Conduplicato corpore”- doubled upon itself
• Cesarean delivery

66. Compound presentation
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• It is the presence of a
limb alongside the
presenting part(head)
• It can be vertex with a
single or double hand or
feet
• A breech with a single or
double hand felt
alongside the breech.
• If the hand is felt alone,
not alongside with
presenting part, then it
is a “hand prolapse”

69. Mechanism of labor
• The usual progress in a compound presentation
diagnosed in early labor is the gradual regression of
the extremity upward as the vertex is pushed
downwards by uterine action.
• In cases of CPD, the brow may persist and requires
follow up with labor progress and appropriate
management.
• Induction and augmentation and instrumental
deliveries are contraindicated in compound
presentations
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70. Thank You!!!