The document provides a comprehensive overview of malpresentation and malposition in childbirth, detailing definitions, risks to mother and fetus, predisposing factors, and specific conditions like breech, occipito posterior, and face presentations. It outlines management strategies including early diagnosis, monitoring, and various delivery methods depending on the presentation type and associated risks. Emphasis is placed on the importance of trained attendants and appropriate facilities to mitigate complications during labor.

1. MALPRESENTATION AND MALPOSITION

2. Summary:
• Definitions
• Risks on mother and fetus
• Predisposing factors
• Breech. occipito posterior. face. brow.
shoulder, compound.

3. Definitions:
1- Presentation:- leading part of the fetus that
presents to the lower uterine segment.
2- Malpresentation: any other presentation
other than vertex
3- Position: relationship of presenting part to
the pelvic brim.

4. • Definitions (cont):
4- Denominator: Most definable peripheral
point in the presenting part
- Vertex- occiput
- Face- mentum
- Breech- sacrum
5- Position at start of labour
- 90%:LOA,ROA,OA

5. Risks on mother and fetus:
1- Prolonged and obstructed labour
2- Ruptured uterus
3- Difficult C/S, forceps, ventouse-traumatic
delivery
4- Complications of puperperium
5- Vesico vaginal fistula
6- Increased maternal and perinatal mortality

6. Prevention of Risks:
1- Early diagnosis
2- Monitoring
3- Trained attendant
4- Facilities

7. Predisposing factors
1-Pre-maturity
2-Contracted pelvis- malformation
3- Multiple pregnancy
4- Polyhydramnios
5- Big baby
6- Congenital malformation of fetus

8. Predisposing factors (cont):
7- Congenital malformation of uterus
8- Fibroids
9- Placenta Previa
10 Oligohydramnios
11- Pendulous abdomen, grandmultipara

9. BREECH PRESENTATION:
1- Incidence 3-4% at term
2- Denominator sacrum
3- Diagnosis
– Head occupies the fundus (hard, rounded,
ballotable, tender)
– Breech above pelvic brim (broad, soft, irregular)
– Longitudinal lie
– Fetal heart above umbilicus

10. Breech (cont):
– U/S: confirm diagnosis.Diagnose, maturity,
placenta previa, fibroids, fetal malformation,
twins, uterine malformation, liquor.
– Vaginal examination
– Incomplete breech: ischial tuberosities sacrum,
anus
– Complete: feet beside buttocks
– Footling:foot
– Knee: knee

16. Breech (cont):
4- Types of breech:
• Group assignment

17. Breech (cont):
5- Risks to mother:
- Dystocia, sepsis, lacerations, C/S

18. Breech (cont):
6- Risks to the fetus:
6.1 Stillbirth
- Intracranial haemorrhage Rapid moulding and
rapid correction of moulding Rapid uncontrolled
delivery
- Asphyxia Slow delivery. Pressure of cord between
fetal body and pelvic wall
- Medullary coning through foramen magnum
- Spinal cord injury.
6.2 Other injuries ( brachial plexus - femur- liver)
6.3 Intraprtum asphyxia (dystocia, cord prolapse)

19. Breech (cont)
Management Ante partum:
1- Identify cause by U/S
2- External Cephalic Version (ECV)
3- If ECV fail: Decide C/S or assisted vaginal
delivery

20. • Breech (cont)
• ECV:
– In hospital where C/S can be done immediately
– 37 weeks. <37 = per-term. > 37 = difficult
– Success= 60% in multipara
40% in primigravida

21. Preparation (ECV):
– U/S: confirm, back IUGR, liquor
– CTG: 20 min before Procedure . well
– Nothing by mouth
– Empty bladder
– I.V line
– 0.25 mg turbutaline subcutaneous 15 min before
start (tocolytic
– Trendelenberg position

22. Procedure (ECV):
– Elevate breech from pelvis
– Flex fetus and rotate in direction of nose
– Transverse
– Guide head in pelvis
– CTG for 30 min (reactive- no contraction)

24. Procedure (ECV):
–If no success after 15 min stop
–Stop if severe pain or bradycardia
–If bradycardia persists revert ECV
–If still bradycardia C/S

25. • Breech (cont)
Contraindications for ECV:
– Vaginal delivery not possible
– Multiple pregnancy
– IUGR
– Previous C/S
– APH

26. Contraindications for ECV:
– Pre-eclampsia
– Ruptured membranes
– Cardiac disease
– Uterine abnormality
– Rhesus negative

27. Breech (cont)
Complications of ECV:
– Premature labour
– Cord accident
– Abruptio placenta
– IUFD
– Feto-maternal transfusion
– Bradycardia

28. Breech (cont)
Difficult ECV:
– Primigravida
– Obese
– Decrease liquor
– Anterior placenta
– Early labour
– Big baby
– Irritable uterus

29. Breech (cont)
If ECV fails decide: C/S, Vagianl:

30. Elective C/S
– Hypertension, diabetes, APH
– Big baby ≥ 3.8 kg
– Contracted pelvis < 4.5"AP
– IUGR
– Previous SB
– Relative infertility

31. Elective C/S
– Primigravida
– Previous C/S
– Footling
– Hydrocephalus
– Hyperextended head

32. Breech (cont)
Vaginal delivery:
-Adequate pelvis
- Wt: < 3.8 kg
- No complication
- Multipara
- Malformed baby

33. Breech (cont)
Mechanism of labour:
1- Engagement- bitrochantric diameter transverse
and sacrum ventral
2- Anterior hip rotates anteriorly under the pubic
arch
3- Post hip deliver by lateral flexion
4- Baby straightens and anterior hip delivers
5- Legs and feet

34. Mechanism of labour:
6- Ext rotation- shoulders antero posterior
7- Head
– Fixed under pubic arch
– Deliver by flextion (chin-mouth-nose-brow-vertex-
occiput)
8- Keep back anterior
9- Second stage not more than 30 min

35. Breech (cont)
Management during labour:
1- First stage:
– Assess mother-fetus
– Look for cord prolapse
– Monitor mother+fetus
– C/S:fetal distress, maternal distress, failure of
progress (no syntocinon)

36. Management during labour (cont):
2- Second stage:
- The larges part of baby delivers last
- Spontanous
- Extraction(only second twin)

42. Breech (cont):
Assisted vaginal delivery:
1- Empty bladder
2- Cervix fully dilated
3- L ook for cord
4- Sacrum anterior
5- Prineum distended and breech climbs perineum

43. Breech (cont):
Assisted vaginal delivery:
6- Pudendal block
7- Episitomy
8- Delvier buttocks and legs
9- Frank breech: abduct thigh and flex knee
deliver
10- Hold baby back anterior

44. Assisted vaginal delivery (cont):
11- WAIT DO NOT PULL

45. Assisted vaginal delivery (cont):
12- Deliver arms when scapula appears
13- Extended arms due to pulling (LOVSET)
- Rotation of body so that the posterior
shoulder becomes anterior and below pubic
symphysis
14- Leave baby hang by gravity (supported) flexed
and engaged
15- Nape of neck under symphysis pubis

46. Deliver Head:
A- Mauriceau smellie veit Two fingers press over
maxilla to flex the head, suprapubic pressure.
Shoulder traction
B- Swing the trunk towards the maternal
abdomen until the mouth and nose are visible
C- Forceps Piper-Neville Barnes Forceps Long
Forceps when MSV fails

47. OCCIPITOPOSTERIOR (OP) AND
DEEP TRANSEVERSE ARREST:
1- Normally head engages with occiput lateral
(LOL,ROL)
– Usually rotates anterior (OA). 80% well flexed.
Presenting diameters: suboccipito bregmatic+
biparietal 9.5× 9.5 cm
– Rarely delivers occipito lateral (small baby)
2- In 1/5 labour starts with occipitposterior.Usually
ROP
– Good contractions: 80% flexion and rotates anterior
OA
– Rarely rotates to deep transverse arrest - C/S.

48. OP (cont)
3- Head engages as OP
– Small baby and anthropoid pelvis
– No rotation. Deliver face to pubis
4- Persistent occipito posterior
– Defelxed head
– Occipito frontal diameter 4 1/2 11.5 cm
– Large diameter-difficult labour

49. OP (cont)
Associate with:
– Android and anthropoid pelvis
– Epidural analgesia
– Most unknown

50. OP (cont):
Diagnosis:
– Flat abdomen
– Fetal parts anterior
– Difficult to feel the back
– Fetal heart at flanks

51. OP (cont)
Vaginal Examination:
1- Early in labour Head is high and anterior fontanelle
occupies the center. Posterior fontanelle high and
sagital suture anteropsterior
2-Late in labour
– Moulding +caput
– Parietal bones overlap on each other and on the occiput
– Diagnosis difficult, feel ears
– Asymetrical dilatation of Cervix oedema of anterior Lip

56. OP (cont)
Features of labour:
– Back pain
– Prolonged and Obstructed
– Early rupture of membranes
– Cord prolapse
– Lacerations-vagina perineum

57. OP (cont)
Management:
1-Similar to occipito anterior
2- Monitoring
– Fetal distress
– Maternal distress
– Failure of progress
3- In primigravida syntocinon may correct
position

58. OP (cont)
Management:
4- Mode of delivery:
– Spontaneous delivery face to pubis
– Fetal distress or maternal distress or cord prolapse in
first stage=CS
– Failure of progress (after syntocinon) in first stage=C/S
– Fetal distress or maternal distress in second stage and
head not engaged = C/S

59. OP (cont)
Management:
4- Mode of delivery:
– Head not engaged, no FD or MD, second stage =
syntocinon
– Fetal distress or maternal distress or failure of
progress in second stage and head engaged=
– Vacuum: enhance rotation and delivery OA.
– Forceps: Deliver face to pubis
– Manual rotation- flex head+rotate

60. FACE PRESENTATION:
1- Incidence 1:300
2- Aetiology
– Hyperextended head +face presenting
– Submentobregmatic diameter 9.5 cm
– Usually secondary in labour
i- Big baby
ii-Contracted pelvis
iii-Pendulous abdomen of grandmultipara
iv-Premature
v-Goitre, anencephaly

61. • Face presentation (cont):
3- Diagnosis:
Vaginal examination
– Frontal bones, supraorbital ridges, eycs, nose,
mouth, chin.
– Mouth(suckling reflex, alveolar margin, mouth and
maxilla form triangle)
– Anus: Straight line with ischial tuberosities.

63. Face presentation (cont):
4- Labour:
– Face bones not comperssable
– Submento bregmatic diameter 9.5 cm
– Prolonged labour, early rupture of membranes
– Strats mento-lateral and rotates to mentoanterior
– Neck fixed under pubic arch and head delivers by
flexion
– Mento posterior rotates to mentoanterior
– Persistent nentoposterior- impossible vaginal .

64. Face presentation (cont):
5- Management:
– Evaluate condition carefully after diagnosis
– Vaginal delivery – Mento anterior and mento
lateral: Monitor (FD,MD, Failure progress)
– Large episiotomy

65. Face presentation (cont):
5- Management:
– Contra- indicated
• Syntocinon.
• Vacuum
• Scalp electrode
- Forceps may be used

66. Face presentation (cont):
5- Management:
– Caesarean section
• Contracted pelvis
• Big bay
• Previou C/S
• Hypertension, APH, diabetes
• Presistent mento posterior

67. Face presentation (cont):
–Dead fetus
• Craniotomy
• C/S

68. BROW PRESENTATION:
– Incidence 1:600
– Aetiology similar toface
– Deflexed head. Mentovertical diameter 13.5 cm
- Diagnosed by vaginal exam
Frontal sutures, anterior fontanelle, supra
orbital ridges, eyes, nasion (mouth and chin
not felt)
- Management:C/S

69. TRANSVERSE LIE OR SHOULDER
PRESENTATION:
– Incidence 1:300
– Aetiology
• Multiparous
• Pendulous abdomen
• Pre-term
• Placenta previa
• Abnormal uterus
• Contracted pelvis
• Polyhydramios
• Malformed baby

70. Transverse lie or shoulder presentation (cont):
Diagnosis:
– Asymmetrical abdomen
– Fundus less than dates
– Head usually to the left
– In back down transeverse lie the shoulder is over the
pelvic inlet (shoulder presentation)
– In back up transever lie (second twin)
– Oblique lie
– Unstable lie
– Empty pelvis

72. Transverse lie or shoulder presentation (cont):
Vaginal examination:
– Early labour: bag of water with fetal parts
– Late labour: membranes ruptured
– Shoulder presents in back down transevers lie
(ribe in medial side of axilla, clavicle, acromion)
– Arm proplapse.

73. Transverse lie or shoulder presentation (cont):
Features of labour:
– Ruptured membranes+cord proplapse
– Obstructed labour ruptured uterus
– Neglected shoulder presentation

74. Transverse lie or shoulder presentation (cont):
Management Antepartum:
1- U/S (Placenta previa etc)
2- Attempt ECV
3- C/S
• Management in labour:
– C/S

75. PROPLAPSE AND PRESENTATION OF
CORD:
Aetiology:
1- Malpresentaion malposition
2- Multiparous-high head at start of labour
3- Polyhydramnios
4- ARM-high head
5- ECV
6- Forceps-vacuum
7- Long cord
8- Pre-term.

76. Prolapse and presentation of the cord (cont):
1- Proplapse: Membranes ruptured
- Diagnosed: visual, vag examination Bradycardia
: Cord spasm. Compressed. Asphyxia
2- Presentation: membranes not ruptured (C/S)

77. • Management of Prolapsed cord:
1- Keep cord in vgina
2- Elevate foot of bed.fill bladder
3- Never attempt to reposition in uterus
4- Forceps:alive +fully dilated cervix
5- C/S:alive
6- Vaginal: dead.

78. THANK YOU