This document defines malpresentations as any fetal position other than vertex presentation. It discusses the most common types including breech, brow, shoulder, face, compound, and parietal bone presentations. Causes of malpresentations include prematurity, high parity, fetal anomalies, and others. Incidence rates are provided for different presentation types. The document then goes into further detail about breech, face, brow, transverse lie, and compound presentations, defining each type, discussing causes, diagnosis, management considerations, and risks. Management may include external cephalic version, cesarean delivery, or attempted vaginal breech delivery depending on the situation.

1. MALPRESENTATIONS
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2. Definition
 Any presentation other than the vertex
.
 Incidence: up to 5% of term
pregnancies
 Incidence is high with preterms
 Pathophysiology
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3. MALPRESENTAIONs
 INCLUDES
◦ BREECH
◦ BROW
◦ SHOULDER
◦ FACE
◦ COMPOUND
◦ PARIETAL BONE PRESENTATIONS
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4. CAUSES OF
MALPRENTATION
 Prematurity
 High parity
 Fetal anomalies
 Polyhydramnios
 Contracted pelvis
 Placenta previa
 Uterine anomalies
 Space occupying
lesions (eg, uterine
leiomyomata)
 Impaired fetal
mobility:
◦ Crowding from
multiple gestation
◦ Neurologic
impairment
◦ Short umbilical cord
◦ Fetal asphyxia
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5. Incidence
Type of
presentation
Incidence
Breech 3-4%
Face 0.2%
Brow 1/1500
Transverse lie 0.33%
Compound
presentation
1/1000
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6. Breech Presentation
 The commonest malpresentation
 Complicates 3–4% of all pregnancies,
 Occurs when the fetal pelvis or lower
extremities engage the maternal pelvic
inlet.
 Has higher perinatal mortality and
morbidty
 Causes of breech presentation-
◦ prematurity, multiple pregnancy, fetal
malformation, uterine malformation,
hydramnious…

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7. Types of Breech presentation
 Three types of breech are
distinguished, according to
fetal attitude.
 Frank breech, the hips are flexed with
extended knees bilaterally.
 Complete breech, both hips and
knees are flexed.
 Footling breech,
◦ 1 (single footling breech) or
◦ both (double footling breech) legs are
extended below the level of the buttocks.
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8. Types of Breech presentation
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9. Positions/Breech Presentation
 Fetal position in breech presentation
is determined by using the fetal
sacrum as the point of reference to the
maternal pelvis.
 Eight possible positions are
recognized:
 SA, SP, LST, RST, LSA, LSP, RSA,
and RSP.
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10. Pathogenesis
 Hypothesis:
 maternal, fetal, or placental conditions,
 In most pregnancies, however, breech
presentation appears to be a chance
occurrence.
 Abnormalities of the
uterus and/or fetus account for less
than 15 % of breech presentations.
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11. C/M AND DIAGNOSIS
 Hx: the mother is more likely to report
subcostal discomfort She may perceive
kicking in the lower abdomen
 Leopold
 PV exam during labor
 Ultrasound
◦ It confirms the clinical diagnosis
◦ Fetal congenital abnormality, congenital
anomalies of the uterus, & placental location.
◦ It measures GA & approximate weight of the
fetus
◦ Attitude of the fetus
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12. MANAGEMENT OF BREECH
PRESENTATION AT TERM
Management options
(1) external cephalic version
(2) elective caesarean section
(3) trial of vaginal delivery
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13. MANAGEMENT cont’..
Candidates of breech VD Indications for C/D
Adequate pelvis Big baby ( EFW > 3500
gms)
Average fetal weight(2000
- 3500 gms)
Hyper extension of the
head
Flexed head and without
any other complication
Footling breech
presentation
frank breech is preferred Suspected pelvic
contraction
Complete breech Any associated obstetric
complication
Delivery of preterm breech
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15. Types OF Breech Vaginal
Delivery
 Spontaneous Breech Delivery
 Partial Breech Extraction
 Total Breech Extraction
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16. Planned C/D vs planned VD
 Term breech trail
 WHO study
 PREMODA
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17. Delivery Complications
 Cord prolapse
 Birth trauma
 Trauma is more common with vaginal
births, but fetal trauma is also seen
with C/D.
 Entrapment of after coming head
 Genital tract laceration
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18. FACE AND BROW
PRESENTATION
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19. Face Presentation
 The neck is hyperextended so that the
occiput is in contact with the fetal back.
 The chin (mentum) is presenting part.
 Most MP convert spontaneously to MA
even in late labor, some persist.
 If not, the fetal brow (bregma) is pressed
against the maternal symphysis pubis.
 This position precludes flexion of the fetal
head necessary to negotiate the birth
canal.
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20. 1/16/2024 20

21. BROW PRESENTATION
 Fetal neck extended, but not to the
degree in face presentation.
 The area presenting in the birth canal
typically extends from the anterior
fontanelle to the brow
 but does not include the mouth and chin.
 The brow presentation is often a
transitional
 Persistent brow presentation is not
compatible with vaginal birth unless the
fetus is very small.
 Frontum/bregma is presenting Part
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26. Diagnosis
 Face and brow presentations are diagnosed
by vaginal examination.
 A breech may be mistaken for a face
presentation.
 Namely, the anus vs mouth, and the ischial
tuberosities vs malar prominences.
 Landmarks indicating brow presentation are
the ability to palpate the forehead, saddle of
the nose, and orbits.
 Face presentation is excluded because the
mouth and chin are not palpable.
 incidence of 1 in 600, or 0.17 percent. Face
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27. Etiology
 include conditions that favor extension or
prevent head flexion.
 In exceptional instances, marked
enlargement of the neck or coils of cord
around the neck may cause extension.
 Othes …..
◦ Fetal malformations, hydramnios, contracted
pelvis, High parity,
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28. Management
 Early labor
 Persistant brow/face presentation
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29. Transverse Lie
 longitudinal axis of the fetus is
perpendicular to the long axis of the
uterus
 A transverse lie can occur in either of two
configurations:
◦ "back-up" or dorsosuperior),
◦ "back-down" or dorsoinferior),
 When the long axis forms an acute
angle, an oblique lie/ unstable lie results.
 Acromion is presenting part
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30. 1/16/2024 30

31. ETIOLOGY
1. Abdominal wall relaxation from high
parity,
2. Preterm fetus,
3. Placenta previa,
4. Abnormal uterine anatomy,
5. Hydramnios, and
6. Contracted pelvis.
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32. Complications
 Increased operative delivery
 Fetal injury
◦ Fracture of long bones
 Cord prolapse(20%)
 Obstructed labor and uterine rupture if
not managed properly
 High perinatal mortality and morbidity
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33. Management
 Active labor….. C/D
 Before or early labor
◦ ECV
◦ Elective C/S
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34. Compound Presentation
 Extremity prolapses alongside the
presenting part
 Causes are conditions that prevent
complete occlusion of the pelvic inlet by
the fetal head,
 Including preterm labor.
 The combination of an upper extremity
and the vertex is the most common.
 Diagnosis is made by vaginal
examination
 Labor is not necessarily contraindicated
with a compound presentation;
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35. Risks
 Fetal risk: birth trauma, cord prolapse (11 –
20%), neurologic and musculoskeletal
damage.
 Maternal risks include soft tissue damage
and obstetric laceration.
 However, the prolapsed extremity should not
be manipulated.
 75% of vertex/upper extremity combinations
deliver spontaneously.
 Occult or undetected cord prolapse is
possible
 The primary indications for surgical
intervention are cord prolapse, non-
reassuring FHR, and arrest of labor.
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36. Reading assignment
 Maneuvers in breech vaginal delivery
 External cephalic version
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