This document discusses malpresentation and malposition during childbirth. It defines malpresentation as any non-vertex fetal position and lists the main types as face, brow, breech, shoulder, and compound. Factors that can increase the risk of malpresentation include diminished uterine cavity polarity, increased or decreased fetal mobility, an obstructed pelvis, and fetal malformations. The document outlines the management and risks associated with different malpresentation types, noting that while some may allow for vaginal delivery, cesarean delivery is often recommended when normal progress stalls.

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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4. 2/23/2016 4

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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23. 2/23/2016 23

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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32. 2/23/2016 32

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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36. 2/23/2016 36

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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63. 2/23/2016 63

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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