malpresentation and malposition

2. FACE PRESENTATION

3. FACE PRESENTATION
Definition:
a variety of cephalic presentation where
presenting part is face.
- Head is fully extended on the neck.
_ Denominator is mentum (chin)
Incidence:
- 1:300 labour.

4. Causes:
Maternal & Fetal
Maternal causes.
Multiparity with lax and pendulous abdomen, poor
uterine tone.
Lateral obliquity of the uterus.
Contracted pelvis – flat pelvis.

5. Fetal causes
1. Congenital anomalies.
Anencephaly
Congenital goitre
Congenital tumours of the neck (Cystic hygroma).
1.Increased tone of extensor group of muscles of the neck.

6. Diagnosis:
usually diagnosed in labour.
1.Clinical examination
Abdominal examination
Mento-anterior . .
 Fetal limbs felt anteriorly
 Groove between the head and back is not so prominent.
 FHS distinctly audible.

7. Mento-posterior:
Fetal back felt anteriorly.
Groove between head and back is prominent.
FHS not so distinct,audible on the flank.
Vaginal examination:
early labour – high head and elongated bag of waters.
palpation of mouth with alveolar margin.
nose, malar eminences, supraorbital ridges and mentum.
differentialdiagnosis,breech
sucking effect of mouth.
hard alveolar margin.
absence of meconium.

8. Management
Management depends on:
(1) pelvic adequacy.
(2) size of baby.
(3) presence of fetal abnormalities.
(4) position of mentum.
(5) associated complicating factors, elderly primigravida and PE.
Position of Mentum:
Mento-anterior position. . . vaginal delivery.
Mento-posterior position. . rotate to mento-ant. . .vaginal delivery
. . forceps delivery.
Persistent mento-posterior. . . submento-vertical diameter is
11.5 cm → CS.

9. BROW PRESENTATION

10. BROW PRESENTATION
Definition:
a variety of cephalic presentation where the presentation is the brow
and the head lies between full extension and full flexion due to
deflexion.
Causes: same as face presentation.
Diagnosis:
1. Abdominal examination.
head feels very big and is not engaged
groove between the head and back is less prominent.
1.Vaginal examination.
supra-orbital ridge,forehead and ridge of nose is felt.

11. Management
1.During pregnancy: persist brow with complicating
factors→ elective LSCS
1.During labour:
 In complicating cases, if spontaneous correction to vertex or
face fail to occur, the presenting diameter, mento-vertical
(13cm) is too large to pass normal pelvis →CS.
 Spontaneous correction of mento-anterior brow to mento-
anterior face or occipito-anterior vertex →vaginal delivery.
 If the baby is dead →craniotomy ( danger of uterine rupture).

12. OCCIPITO-POSTERIOR POSITION

13. OCCIPITO-POSTERIOR POSITION
Definition.
A malposition of vertex presentation where head is
incompletely flexed and engaging diameter is occipito-frontal
(11cm).
Causes.
1.Passage. . anthropoid or android pelvis.
2.Passanger. . Deflexed head
Primary brachycephaly
Attachment of placenta to anterior wall of uterus.
3.Power. . . .Abnormal uterine contractions.

14. Diagnosis
1. Abdominal examination:
Abdomen is flat in the SPA
Fetal parts are easily palpable on both sides of midline
Head is not engaged and feels larger
FHS heard towards the flanks.

15. 2. Vaginal examination (in labour)
Both fontanelles are easily felt
Saggital suture occupies the oblique diameter of
pelvis .
Palpation of the ear may be necessary as moulding and
caput make occiput difficult to recognize.

16. Complications
Head is not well applied to cervix
Early rupture of the membranes
Prolonged first and second stage of labour
Backache and bearing down efforts before full
dilation of the cervix.

17. Management of 1st stage
Partogram – maternal condition
- fetal condition
- progress of labour.
Provide adequate analgesia
Prevent maternal distress and dehydration
If not favourable . . . CS.

18. Management of 2nd stage
 Long anterior rotation of occiput to OA (75%). . normal
vaginal delivery
 Short posterior rotation of occiput- Direct OP. . generous
episiotomy to avoid perineal tears →spontaneous face
to pubes delivery or assisted delivery with vacuum,
Keilland forceps or manual rotation to OA and forceps
delivery
Short anterior rotation to deep transverse arrest →vacuum
extraction, manual rotation and forceps extraction, Keilland’s
forceps, big baby and contracted pelvis →CS.

19. Management of 3rd stage
PPH due to prolonged labour
- active management of 3rd stage.
Genital tract injuries.

20. THANK YOU