this is best lecture power point prepared for clinical year medical students

1. Malpresentation and Malposition
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2. Learning objectives
• Define malpresentation
• Mention pathogenesis for malpresentation
• List different types of malpresentation
• Understand the mode of delivery for each
malpresentation types
• Define malposition
• List types of malposition
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3. • 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.
• Vertex presentation is normal presentation which
accounts 95-96%.
• 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
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5. • Factors associated with malpresentation
include:
1. Diminished vertical polarity of the
uterine cavity,
2. Increased or decreased fetal mobility,
3. Obstructed pelvic inlet, and
4. Fetal malformation
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6. • Diminished vertical polarity of the uterine cavity:
Parity
Myoma
Placentation
Müllerian duct fusion abnormalities such as septate
uterus or uterus didelphys
• Increased fetal mobility
Prematurity
Polyhydramnios
Multiple pregnancy
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7. • CPD
Severe fetal hydrocephalus
Contracted maternal pelvis
• Decreased fetal mobility
Aneuploidies,
Myotonic dystrophy,
Joint contractures from various etiologies,
Arthrogryposis,
Oligohydramnios, and
Fetal neurologic dysfunction that result in
decreased fetal muscle tone, strength, or activity
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8. `
• Variety of maneuvers intended to facilitate vaginal
delivery for malpresentations:
Destructive delivery
Manual or instrumental attempts
Internal podalic version(IPV)
• IPV followed by a complete breech extraction was once
advocated as a solution.
• However, it was associated with:
High fetal or maternal morbidity or mortality rate
& have been largely abandoned.
• C/D has become the recommended alternative to
manipulative vaginal techniques when normal progress
toward vaginal delivery is not observed.
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9. Abnormal Axial Lie
• Fetal “lie” indicates the orientation of the fetal spine
relative to the spine of the mother.
• Unstable lie if the
Fetal membranes are intact & there is great fetal
mobility resulting in frequent changes of lie or
presentation.
• Abnormal fetal lie is diagnosed:
1 in 300 cases, or 0.33% of pregnancies at term.
2% of pregnancies at 32 weeks, or six times the
rate found at term.
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10. • Persistence of abnormal lie >37 weeks requires a systematic clinical assessment &
a plan for mx, b/c rupture of membranes imposes high risk of:
Cord prolapse,
Fetal compromise, and
Maternal morbidity if neglected.
• Any condition that alters the normal vertical polarity of the intrauterine cavity will
predispose to abnormal lie.
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11. • Diagnosis of the abnormal lie: made by
Palpation or
Vaginal examination and
Verified by ultrasound.
• Sensitivity of Leopold’s maneuvers for the detection of
malpresentation to be only 28- 41% .
• Fetal loss rate of:
9.2% with an early diagnosis
27.5% with a delayed diagnosis indicates that early
diagnosis improves fetal outcome.
• Perinatal mortality rate for unstable or transverse lie
varies from 3.9% to 24%, with maternal mortality as
high as 10%.
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12. • Maternal deaths are usually related to:
Infection after PROM,
Hemorrhage secondary to abnormal placentation,
Complications of operative intervention for CPD , or
traumatic delivery
Uterine rupture
• Fetal loss of phenotypically & chromosomally normal is
primarily associated with:
Neglect
Prolapsed cord or
Traumatic delivery.
• Cord prolapse occurs 20 times as often with abnormal lie as
it does with a cephalic presentation
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13. Transverse lie
• Long axis of the fetus is perpendicular to
that of the mother
• Incidence 0.3%
• Shoulder is over the pelvic inlet
(shoulder presentation)
• Side of the mother on which the
acromion rests determines the
designation of the lie as Rt or Lt acromial
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14. Diagnosis
Inspection:
• Wide abdomen, the fundus extends to
only slightly above the umblicus
Palpation
• No fetal pole in the fundus
• Ballotable head found in one iliac
fossa and breech in the other.
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15. Vaginal Exam
 Early stage of labor: gridiron feel of
the ribs of the thorax
 Further dilatation: scapula and
clavicle
 Late labor: shoulder tightly wedged in
the pelvic canal
 Arm prolapse in to the vagina
U/S and X-ray are confirmatory
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16. Etiology
• Abdominal wall relaxation from high
parity
• Preterm fetus
• Placenta previa
• Abnormal Ux anatomy
• Excessive amniotic fluid
• Contracted pelvis
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17. Management
• Spontaneous delivery of fully developed
fetus is impossible
• C/delivery – in established labor
• ECV – before labor or early labor with
intact membrane
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18. MX Of a singleton with malpresentation
• Safe vaginal delivery of a fetus from an abnormal lie
is generally impossible
• Search for the etiology of the malpresentation.
• Transverse/oblique/unstable lie late in the 3rd TM
Necessitates ultrasound examination to exclude a
major fetal malformation & abnormal
placentation.
• Elective hospitalization:
Observation
Early recognition of cord prolapse, and
Provides proximity to immediate care.
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19. • Active intervention @:
≥37 weeks or
After confirmation of fetal lung maturity .
• ECV with subsequent induction of labor, if successful.
• ECV a reasonable alternative to both expectant mx &
elective C/D.
• C/D is the Rx of choice for the potentially viable infant
if:
ECV unsuccessful or unavailable
Spontaneous rupture of membranes occurs
Active labor has begun with an abnormal lie.
• No place for internal podalic version in the mx of
abnormal lie.
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20.  Attitude: position of the fetal head in relation to the neck.
 Normal attitude of the fetal vertex during labor is full flexion on the neck.
 Deflexed attitudes include various degrees of deflection
 Although safe vaginal delivery is possible in many cases, C/D is the only
appropriate alternative when arrest of progress is observed.
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21. INCIDENCE OF
MALPRESENTATION
• 96% of fetuses at term will present with vertex.
• 91.4% of fetuses present in vertex , occiput anterior (OA).
• Fetuses that are not in vertex presentation are considered to
have a malpresentation.
• At term, the types & estimated incidences of malpresentations
are:
Breech (1/33 deliveries)
Cephalic malpresentations (1/18 deliveries)
Face (1/600 to 1/800 deliveries)
Brow (1/500 to 1/4000 deliveries)
Compound (1/1500 deliveries)
Transverse lie (1/833 deliveries)
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22. FACE PRESENTATION
• Fetal neck is sharply deflexed, allowing the occiput
to touch the back and the face (from forehead to
chin) to present in the birth canal
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24. Etiology and risk factors
• It is presumed to occur because of factors that:
 Favor extension or
 Prevent flexion of the fetal neck.
• A common risk factor is:
 An anomalous fetus (anencephaly, massive hydrocephalus, or an anterior
neck mass).
 Multiple nuchal cord loops
 Other factors includes:
 CPD
 Prematurity/low birth weight
 Macrosomia
 Contracted maternal pelvis & platypelloid pelvis
 polyhydramnios
 Black race and Multiparity
 Extreme laxity of the anterior abdominal wall
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25. Diagnosis
• Usually made late in the 1st or 2nd stage of
labor.
• On digital examination, landmarks are
palpating:
Orbital ridge and orbits,
Saddle of the nose
Mouth, and chin.
• Sonography = will show a hyper extended fetal
neck.
• Although imaging studies can be performed it is
not mandatory.
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26. 2/23/2016 26

27. Course and management of labor
• At the time of diagnosis:
60 % will be in the MA position
26 %will be MP and
15 % will be MT.
• 30-50% of MP & MT positions will spontaneously
convert to the MA position during the course of labor.
• Mx requires close observation of the progress of labor
b/c CPD is more likely than with vertex presentation.
• The widest diameter of the fetal head negotiating the
pelvis in face presentation is the trachelo-bregmatic or
trachelo-parietal diameter average length 12.6 cm.
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28. • Despite the increased diameter, >75% of
MA are delivered vaginally,
• Whereas persistent MP & MT fetuses
require cesarean birth
• Abnormalities of the fetal heart rate
occur more frequently with face
presentations
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29. Mentum anterior
• Once engagement has occurred in MA, fetal
neck extends even further backward such that
the occiput touches the back.
• Internal rotation occurs b/n the level of
ischial spines & ischial tuberosities , making
the chin the actual presenting part of the face.
• As the face descends onto the perineum, the
fetal chin passes under the maternal symphysis
pubis, slight flexion of the neck occurs.
• Parturient may begin pushing at full dilatation.
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30. • Oxytocin augmentation:
If indicated and
Fetal heart rate pattern is reassuring.
• Outlet forceps should only be used by experienced
practitioners.
• Since engagement does not occur until the face is at +2
station, forceps should only be applied to the face that is
bulging the perineum.
• Attempts at:
Version,
Extraction, or
Midforceps delivery should be avoided, as they are
associated with unnecessary maternal trauma and
neonatal injury
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31. Mentum posterior
• In the MP position: the neck, head, & shoulders
must enter the pelvis simultaneously;
• However, the pelvis is usually not large enough to
accommodate.
• Also the fetal neck must extend the length of
the maternal sacrum (average 12 cm) in order to
reach the perineum.
• Lastly, an open fetal mouth may act as a fulcrum
against the sacrum preventing further descent.
• Therefore, MP will not deliver vaginally unless:
Spontaneous rotation occurs or
Fetus is very small (eg, very preterm)
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33. Brow presentation
• Portion of fetal head b/n orbital ridge & the anterior
fontanel presents at the pelvic inlet
• Rarest (o.o6%)
• Presenting diameter is mento-vertical (mento-
parietal (or mento-bregmatic)) (13.5cm)
• Unstable commonly often converts to face or
vertex presentation.
• Fetal head occupies a position midway b/n flexion
(occiput) & extension (face)
• Engagement can’t take place ;unless head is small or
pelvis is very large
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34. Diagnosis
Abdominal palpation: occiput & chin
palpated easily
PV: frontal suture, large anterior fontanel
Orbital ridge & Eyes
Root of nose felt
Etiology
Same as face
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35. Mechanism of labor
• Very small fetus & large pelvis labor is
possible.
• Large fetus: engagement is impossible
until marked moulding shortens
occipitomental ø (13.5cm).
• Caput succedaneum: is over the forehead.
• Managed by C/S unless small fetus with
roomy pelvis.
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37. 2/23/2016 37

38. Compound presentation
• An extremity prolapse along side the presenting
part with both presenting in the pelvis
simultaneously
Cause:
Condition that prevents complete occlusion
of the pelvic inlet by the fetal head.
Management
The prolapsed part should be left as it is.
It will not interfere with labor
Retracts out of the way with descent of the
head
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39. Prognosis
Increased perinatal loss
Preterm delivery
Cord prolapse
Traumatic obstetrical procedures
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40. BREECH PRESENTAION
• The term derives from the same word as
britches, which described a cloth covering the
loins and thighs.
• There are three major types of breech
presentation:
Frank(50-70%)
Incomplete(10 to 40%)
Complete(5-10%)
kneeling
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41. Frank breech
The lower extremities are flexed at the hips and
extended at the knees.
Incomplete breech
One or both feet felt below the breech
A foot or knee is lower most in the birth
canal
Complete breech
One or both knees are flexed
The feet may be felt along side the
buttocks
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43. 2/23/2016 43

44. PREVALENCE
20 to 25% of fetuses under 28 weeks are
breech,
only 7 to 16% are breech at 32 weeks, and
only 3 to 4% are breech at term
Spontaneous version may occur at any time
before delivery, even after 40 weeks of
gestation.
Likelihood of spontaneous version to
cephalic presentation after 36 weeks is
25%.
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45. PATHOGENESIS AND RISK
FACTORS
• Altered intrauterine contour or volume:
Uterine anomalies (eg, bicornuate or septate uterus)
Space occupying lesions (eg, uterine leiomyomata)
Placental abnormalities (eg, PP, cornual placenta)
Multiparity
Extremes of AFV (polyhydramnios, oligohydramnios)
Contracted maternal pelvis
• Altered fetal shape:
Fetal anomaly (eg, anencephaly, hydrocephaly,
sacrococcygeal teratoma, neck mass)
Extended fetal legs
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46. • Impaired fetal mobility:
Crowding from multiple gestation
Neurologic impairment
Short umbilical cord
Fetal asphyxia
• Other purported risk factors include:
Primiparity
Female gender
Maternal anticonvulsant therapy
Older maternal age
Fetal growth restriction, and
Previous breech presentation
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47. • Risk of breech presentation in a 2nd
pregnancy:
9% if the first infant was breech and
2% if the first infant was non breech .
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
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48. Diagnosis
Abdominal palpatión
• Hard , round, ballotable, fetal head occupy the
fundus
• The softer, breech in the LUs above the pelvic inlet
• FHB will be heard more easily at or above the
umbilicus
Vaginal exam
Frank breech
• Ischial tuberosity , sacrum , anus felt
• External genitalia , genital groove after further
descent
• Footling or complete breech __ foot may be felt
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49. Face presentation esp. in prolonged labor
• 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.
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50. Imaging studies
U/S:
Confirmatory
Fetal anomaly
Type of breech, status of head
Estimation of fetal Wt (size)
X-ray:
Confirm the diagnosis (if u/s not available)
Determine the attitude
For pelvimetry
Other: CT, MRI
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51. Management
• Ante partum
 Follow closely for spontaneous version
 If persists ECV
• Labor and delivery
Absolute indications for C/delivery
large fetus ( EFW >3500gm)
Any degree of pelvic contracture
Hyper extended head
Footling breech
Ux dysfunction
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52. • Other obstetric indications for C/S
Sever IUGR
Breech with poor obstetric performance
(previous perinatal death ,Hx of infertility )
Elderly primigravida
Others:
Request for sterilization
Lack of an experienced operator
Zatuchini – Andros score <4
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53. 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
Add 0
Points
Add 1
Point
Add 2
Points
Parity 0 1 2
Gestationa
l 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
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54. Vaginal delivery
Indications
• No maternal or 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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55. Mechanism of labor
Engagement and descent:
Takes place with the Bitrochanteric Ø 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
Shoulder brought into one of the oblique Ø of the
pelvis
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56. Methods of vaginal delivery
Spontaneous breech delivery
• Delivery occurs without assistance except
support of the infant
• No obstetric maneuvers are applied to the baby
Assisted vaginal breech delivery ( partial
breech extraction)
• Allow spontaneous delivery up to umbilicus
then the delivery of shoulders , arms , and
head assisted
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57. Total breech extraction
• Entire body is manually delivered
• Replaced by c/s except in desperate conditions
Indication:
• Fetal distress in 2nd stage of labor
• Cord prolapse or entanglement around the leg
• Need for expeditious delivery 2nd twin
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58. Total Breech Extraction….con
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59. 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.
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60. Pinnard maneuver
• If no spontaneous delivery of the legs
• Splinting the medial thigh of the fetus with the Position parallel to
the femur and exerting pressure laterally to sweep the legs away
from the mid line.
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62. Delivery of the arms and shoulders
Loϋset maneuver:
 Rotate the fetus by half a circle(180) then reverse the
rotation half a circle
Delivery of the posterior arm followed by anterior
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64. Delivery of the head
A. Mauriceau – smellie – veit maneuver (MSV)
• Index and middle finger of one hand over the maxillae to
flex the head
• Two fingers of the other hand hooked over the fetal neck
• Gentle suprapubic pressure→ by assistant
• Body of fetus elevated toward maternal abdomen
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65. B. Wigand maneuver
like MSV but differs
Assistant not needed to apply suprapubic
pressure
One hand put on the suprapubic area to provide
suprapubic pressure
C. Modified Prague maneuver
• Extraction of the head in a persistent OP
• Flex the head with in the birth canal and results in
delivery of the occiput over the perineum
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66. two fingers of one hand grasping the shoulders of the back-
down fetus from below while the other hand draws the
feet up over the maternal abdomen
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67. Head…
D. Burn’s marshall maneuver
• Allow the wt of the child’s trunk to pull the head
into the pelvis
• Trunk allowed to hang down unsupported ( one
or two min)
• The suboccipital area → if seen delivery could be
by lifting the child up towards the mothers
abdomen
E. Forceps:
 Pipers forceps
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69. MALPOSITIONS
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70. • Position:
–Relation ship of a definite fetal presenting
presenting part o the maternal bony
pelvis.
–The most common position at delivery is
occiput anterior.
• Occiput: with a flexed head (cephalic
presentation)
• Sacrum: with breech presentation
• Mentum (chin): with an extended head (face
(face presentation)
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72. Persistent occiput posterior position
• Most OP rotate to OA
• May be normal in early labor
Cause:
• Precise reason not known
Transverse narrowing of the mid pelvis
When it persists it may cause dystocia
2/3 of OP deliveries occurs with
who were OA at the beginning of
labor
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73. Possibilities for vaginal delivery of OP
 Spontaneous delivery__ if pelvis is roomy
 Forceps delivery as an OP
 Manual rotation to OA followed by spontaneous or
forceps delivery
 The requirements for forceps rotation must be met
before manual rotation
 Forceps rotation to OA and delivery
 Vacuum extraction for rotation, extraction or both
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74. Persistent occiput transverse position
• In absence of pelvic abnormality, it is frequently a
transient position
• Tends to rotate to OA
Cause
– Pelvic dystocia
– Ux dystocia
– Platypelloid or android pelvis
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75. Delivery
• In absence of CPD options of vaginal delivery
• Manual rotation to the occiput anterior or
posterior
• Forceps (Kiellands) in OT position
• Augmentation (if hypotonic ux dysfunction )
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