malposition and malpresentations.pptx

2. Fetal presenting part other than vertex includes
breech, face, brow, transverse, and compound
presentation.

3.  More than one pregnancy (e.g. Multipara,Grand multipara )
 More than one fetus (e.g. Twins)
 Too much or too little amniotic fluid (e.g.
Polyhydramnious,
oligohydramnios)
 Abnormal uterine shape (e.g. Arcuate ,septate, supseptate)
or abnormal growth (e.g Fibroid)
 Placenta previa
 The baby is preterm

4. Presentation
the part of the fetus which occupying the
lower uterine segment
Presentation may be :
(3%)
(0.5%)
Breech
Face
Brow
Shoulder
Compou
nd
3 in 100
1 in 500
1 in 1000
1 in 300
1 in 1000
(0.3%)

6. Vertex 99% Face
Brow

8.  The occiput is in the posterior segment of pelvis,
overlying the sacroiliac joint or the sacrum
 Occipitoposterior position is responsible for most cases
of prolonged labour and second stage delay and is the
most common cause of a mobile head at term
 When the occiput is in front of the sacrum, it is termed
direct Occipitoposterior
 In the right Occipitoposterior, the occiput overlies the
right sacroiliac joint and in left Occipitoposterior, it
overlies the left sacroiliac joint
 Thus,3 positions are described –ROP
, LOP, Direct
Occipitoposterior

11.  1. BACK ON THE RIGHT SIDE
 If the back is to the left as in 70% of vertex presentations, the
chance of a posterior position(LOP) is remote
 this is because of dextrorotation of uterus and the presence
of sigmoid colon on the left
 the foetal back is seen on the right side in 25-30% of vertex
presentations and this predisposes to occipitoposterior(ROP)
 2. ANTERIOR INSERTION OF PLACENTA
 Favours a posterior position by pushing the back of the
head with the broader biparietal diameter posteriorly

12.  3. SHAPE OF THE BRIM
 Influences position
 In anthropoid pelvis, the anteroposterior diameter of
the brim exceeds the transverse diameter
 This pelvis is usually of high assimilation type with an
extra vertebra in the sacrum
 Therefore, inclination of the pelvis is increased and
this
favours Occipitoposterior
 In android pelvis, the inlet is wedge shaped and so the
bulky occiput cannot find space in the narrow forepelvis
 This also predisposes to Occipitoposterior

13.  ABDOMINAL EXAMINATION
 Subumbilical flattening due to the absence of the back
anteriorly
 Back is in one or the other flank and so cannot be felt
clearly
 Limbs are felt easily anteriorly
 Shoulder is felt out in the flanks
 Unengaged or high head at term
 The sinciput and occiput may be at the same level due
to deflexion
 Fetal heart sounds are heard in the flanks and are
frequently indistinct

14.  VAGINAL EXAMINATION
 Early in Labour
 Early rupture of conical bag of membranes
 Sagittal suture in the right oblique diameter of the
pelvis
 Smaller posterior fontanelle in the right posterior
quadrant and diamond shaped larger anterior
fontanelle in the left anterior quadrant
 As the head is deflexed, both fontanelles are easily
palpated

15.  In occipitoanterior position, as the head is
well flexed, the posterior fontanelle will be
easily felt, but not the anterior fontanelle
 On the other hand, in Occipitoposterior, the
head is usually deflexed and so the
anterior fontanelle will also be felt with
ease

16.  LATE IN LABOUR
 A large caput may be present obscuring the sutures
 The pinna always points the occiput
 Perineum gapes much before the head distends it
and premature straining can occur
 Difficulty in applying forceps in unrecognised
occipitoposterior

17.  Occipitoposterior position is the
common cause for prolonged labour in
a vertex presentation
 The mechanism of labour will depend upon
whether the vertex is well flexed. in
occipitoposterior position with a well flexed
head, the occiput being the lower will touch
the pelvic floor first and rotate anteriorly and
labour proceeds normally

18.  However due to the longer internal rotation
in occipitoposterior(3/8 of a circle) labour will
naturally be prolonged
 In some occipitoposterior positions, the head
is deflexed and this may result in further delay
in rotation or malrotation

19.  Deflexion may be due to when the back is
posterior, the convexity of the fetal spine abuts
against the convexity of the maternal spine
causing extension of the head
 Hence large diameter present to the pelvic inlet
and the occiput is no longer the leading part.
This is also known as relative disproportion
 Another problem is that in OPP
, the biparietal
diameter occupies the smaller sacrocotyloid
diameter which is encroached upon by the
sacral promontory
 And hence the labour is further arrested

20.  Suboccipitofrontal diameter in a deflexed head
is 10.5cm
 Occipitofrontal diameter in a head which
is further deflexed is 11.5cm

21.  1. Anterior rotation
 In 90% of cases, the occiput rotates anteriorly through
3/8of a circle and the baby is born as occipitoanterior.
Engagement may be delayed and labour may be
longer because of the dorsiflexion
 2. Posterior rotation and face to pubis delvery
 When the head is deflexed, the engaging diameter is
the occipitofrontal and sinciput is the leading part.
Hence the sinciput touches the pelvic floor first and
rotates anteriorly. The occiput thus rotates posteriorly
into the hollow of sacrum and delivery occurs as face to
pubis.
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yextreme flexion followed by
extreme

22.  Perineal tears are common as the occiput is
posterior and it is the longer biparietal
diameter(9.4), which distends the perineum rather
than the smaller bitemporal(8cm). Hence liberal
episiotomy should be given.
 3. Failure of rotation
 Per
rotation
sistent
and
occi
the
pitopost
head
erior is the a
b
s
e
n
c
e
of
remains ROP or LOP

Deep
s
t
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e
a
r
tr
d
ansve
w
i
t
h
rs
t
h
e
e ar
s
a
g
rest is defined as the
head being
diameter at the level
ittal suture in the
transverse
dilatation of cervix
of ischial spine,

23.  REASONS FOR FAILURE OF ROTATION
 Deflexion of the head
 Inefficient uterine contraction
 Weak pelvic floor preventing anterior
rotation
 Cephalopelvic disproportion and android
pelvis

24.  Most of the malposition will rotate anteriorly
and the baby will be born spontaneously as
occiput anterior
 Alternatively, they may rotate posteriorly
and deliver as face to pubis which need
liberal episiotomy.
 As the labour is longer, judicious use of fluids
and analgesia is needed.
 Epidural analgesia is ideal.

25.  1. CAESAREAN SECTION
 The pelvis should be reassessed and if the pelvis is
android or there is evidence of disproportion,
CAESAREAN SECTION should be done
 Increasing use of caesarean for deep transverse
arrest is to avoid the intracranial haemorrhage due
to traumatic vaginal delivery

26.  2. VACCUM EXTRACTION
 This is an alternative in the absence of
cephalopelvic disproportion.
 It promotes flexion thereby reducing the diameter
presenting to the outlet from occipitofrontal to
smaller suboccipitobrgmatic.
 It is less traumatic and does not need general
anaesthesia
 The cup should be applied as near posterior
fontanelle as possible as in order to promote flexion
and smooth descent .

27.  3. MANUAL ROTATION
 This procedure can be employed if the obstetrician
is well versed in this technique.
 Under the general anaesthesia, the right hand
grasps the sinciput displacing it thereby increasing
flexion.
 The smaller bitemporal diameter allows more space
for the thumb and finger to have a firm grasp
across the temple with middle finger on the frontal
suture. In LOP, the left hand is used. Then the
sinciput is rotated and forceps or vaccum is applied

28.  4. FORCEPS ROTATION
 In deep transverse arrest Keilland forceps is used.
 It should be used only by the obstetrician who are
expert in its use.
 It is widely used in UK but it is not popular in
India.
 Keilland forceps is applied under General
Anaesthesia in the anteroposterior direction and
rotation carried out

30.  This is a cephalic presentation where the attitude is one
of complete extension, presenting part is the face
(area between chin and glabella)and denominator is
the chin or mentum.
 Primary face presentation: present before the onset
of labour and are rare
 Secondary face presentation: caused by extension
during labour.( E.g. . left mentoanterior is a result of
extension of right Occipitoposterior)

31.  The engaging diameter is submentobregmatic
9.4 cm

33.  Maternal
 Contracted pelvis
 Oblique of uterus
 Multiparity and pendulous abdomen
 Fetal
 Anencephaly and iniencephlaly
 Cord round neck
 Tumor of neck like congenital goiter
 Spasm of sternocleidomastoid muscle
 Dolichocephalic head

34.  Abdominal examination
 In mentoanterior, back is felt with difficulty as it is
posterior and limbs are felt anteriorly
 Head remains high
 Cephalic prominence is the occiput and on the
same side as the back
 Groove between the head and back is prominent
 Fetal heart sound are transmited through the chest
and heart well anteriorly in mentoanterior

35.  Vaginal examination
 Conrical bag of membranes
 Chin, mouth, nose, mala eminences, and
supraorbital ridges are felt
 In mentoanterior, chin is in one anterior quadrant
and forehead in the opposite posterior quadrant

36.  Mentoanterior posterior
1. Engagement

the engagement diameter is
submentobregmatic. In face presentation, the
biparietal diameter is 7 cm behind the face unlike
in vertex, where it is only 3-4 cm distance.
 The biparietal diameter will pass through the inlet
only when the face is low down in the perineum.
When the face is distending the vulva (crowning),
the head has just engaged.

37. 2. Descent with increasing
extension
 Descent is brought by the same factors as in vertex
presentation.
 When resistance is encountered by a process of
extension, the occiput is pushed towards the back
of the fetus, while the chin descents.

38. 3. Internal rotation
 On further descent, the chin reach
0
es the pelvic
floor and rotates anteriorly through 45 towards
the symphysis.
 Anterior rotation does not take place until the
face is well applied to the pelvic floor and may be
delayed. Only internal rotation takes place this
manner, can the neck travers the posterior surface
of the symphysis pubis.

39. 4.
flexion
 The head is born by flexion. The chin pivots under
the symphysis pubis and the mouth, nose, orbits,
forehead, vertex and occiput are born by flexion
5.Restitution and external rotation
 Restitution and external rotation of chin occurs
towards the side to which it was originally directed,
and the shoulder are born as in vertex

40. Mentoposterior position
 2/3 of cases anteriorly through 3/8 of a circle
and deliver as mentoanterior. Of the rest, some
remain in the oblique diameter and some
rotate posteriorly into the hollow of sacrum.
 In these cases of persistent mentoposterior, the
neck is too short to span the 12cm of the
anterior aspect of sacrum.

41.  The shoulder also get impacted along with
the head making delivery impossible.
 The engaging diameter is the
sternobregmatic, which is about 17cm. Hence,
there is no mechanism of labour in
mentoposterior

42.  Cause of prolonged labour in
face
 Face is less effective dilator of cervix
 No moulding of face
 More chance of premature rupture
of membrane
 Long internal rotation in
mentoposterior
 Internal rotation occurs only late in
the second
stage

43. complication
prolonged and complicated labour
Maternal distress … dehydration … keto acidosis
Infection
obstructed labour → uterine rupture
→maternal death
Fetal
complication
R
up
tu
re
of
fet
Increase in maternal and fetal morbidity and mortality
Maternal
complication

44.  Evaluate the cephalopelvic disproportion
or other associated complication and in
such situation, caesarian section is done.
 If there is no disproportion and position
is mentoanterior, labour can be allowed
to progress.
 In persistent mentoposterior, cescerian section
is done.

46.  It is the least common among
cephalic presentation and most
unfavorable.
 The attitude is one of partial extension ,
the presenting part being the area
between the anterior fontanelle(bregma)
above and the glabella and orbital ridges
bellow and denominator is the forehead
or frontum.

47.  The presenting diameter is verticomental 13.5
cm, which is largest of fetal head

48.  It is about 1in 1000 birth
 The cause is similar to face presentation and
include any factor that interferes with flexion
of the head

49.  - Left fronto-anterior.
 - Right fronto-anterior.
 - Right fronto-posterior.
 - Left fronto-posterior.

50.  Abdominal examination
 High mobile head, which feels large from side to
side
 Cephalic prominence is the occiput and is on the
same side as the back and the groove between the
cephalic prominence and the back is less prominent
than in face presentation

51.  Vaginal examination
 Conical bag of membrane may be felt in early
labour
 Anterior fontanelle(bregma) is felt at one end and
root of nose(nasion)and orbit ridges at the other
end of an oblique or transvers diameter.
 Sometimes, the nose and the mouth are palpable,
but not the chin.

52.  As such, ther is no mechanism of labour
for persistent brow presentation.
 Spontaneous delivery is unlikely and can occur
only when there is a very small baby and
large pelvis.
 In persistent brow, the verticomental diameter
is shortened and the occipitofrontal diameter
is elongated with marked moulding and a
large catput on the forehead

54. complication
Increase in maternal and fetal morbidity and mortality
Maternal complication
prolonged and complicated labour
Maternal distress … dehydration … keto acidosis
Infection
No engagement of presenting part
obstructed labour → uterine rupture →maternal
death
fetal complication
Rupture of fetal membranes
cord prolapse → fetal distress →fetal death

55.  Antepartum
 It is better to wait until the onset of labour in
the hope that correction to vertex or face.
 Early labour
 Cesarean section should be done. If diagnosis in
early labour before rupture of membrane, a short
period of time can be given under close supervision
in the hope of spontaneous correction.

56.  Late labour
 It there is feature of obstructed labour, cesarean
section is performed immediately even if the fetus is
dead.