This document outlines various fetal malpresentations and malpositions that can occur during labor and delivery. It discusses normal presentation and position, as well as abnormal presentations including occiput posterior, face, brow, breech, transverse lie, shoulder, and compound. For each presentation, the document describes causes, diagnosis techniques including Leopold's maneuvers and ultrasound, and approaches to delivery management. Breech presentation is discussed in particularly depth, outlining types of breech, risk factors, techniques for external cephalic version and vaginal breech delivery.

1. Malpresentations & Malpositions
By: Abdulrahman Hussein Karaki
Supervisors: Dr. Osama Alhasany
Dr. Thana’ Abu Fara

2. Referances:
•Kaplan 2021
•2017 Obstetrics by ten teachers 20th ed
•ALSO 2017

3. Outline:
1. Introduction.
2. Diagnosis.
3. Normal position and presentation.
4. OP Position.
5. Face Presentation.
6. Brow Presentation.
7. Breech Presentation.
8. Other fetal malpresentations.

4. Introduction
• ORIENTATION (Lie): Relation between the long axis of the fetus to the long axis of the uterus.
1. Longitudinal: fetus and mother in same vertical axis.
2. Transverse: fetus at right angle to mother.
3. Oblique: fetus at 45° angle to mother.

5. Introduction
• Presentation: Portion of the fetus overlying the pelvic inlet.
1. Cephalic: head presents first.
2. Breech: feet or buttocks present first.
3. Shoulder: presents first.
4. Compound: more than one anatomic part is presenting.
Cephalic Breech Shoulder Compound

6. Introduction

7. Introduction

8. Introduction
• Position: Relationship of a definite presenting fetal part to the maternal bony pelvis.
1. Occiput: with a flexed head (cephalic presentation).
2. Sacrum: with a breech presentation.
3. Mentum (chin): with an extended head (face presentation).

9. Introduction
• Station: Degree of descent of
the presenting part through
the birth canal; expressed in
centimeters above or below
the maternal ischial spine.

10. Introduction
• Attitude: Degree of extension-flexion of the fetal head with cephalic presentation.
1. Vertex: head is maximally flexed.
2. Military: head is partially flexed.
3. Brow: head is partially extended.
4. Face: head is maximally extended.

11. Introduction
• Diameters:
1. Suboccipito-bregmatic (9.5cm): Vertex.
2. Occipito-frontal (11.5cm): Military.
3. Occipito-mental (13cm): Brow.
4. Subhmento-bregmatic (9.5cm): Face.

12. Introduction

14. Diagnosis
• Leopold’s Maneuvers (abdominal palpation).
• Vaginal examination.
• Imaging: ultrasound.

15. Normal
• ORIENTATION (Lie): Longitudinal.
• Presentation: Cephalic.
• Position: Occiput anterior.
• Attitude: Vertex.
• Diameter: Suboccipito-bregmatic.

16. OP Position
• The fetus lies with its occiput toward the woman’s
spine and its face toward the woman’s symphysis
and abdomen.
• The exact cause of persistent OP positioning is
unknown, but transverse narrowing of the pelvis
plays a role.
• All OP fetuses are somewhat deflexed because the
vertex drops back to fill the hollow of the sacrum.

17. OP Position
• Diagnosis: (difficult)
Back pain, or back labor (hallmark).
Examination.
 Palpation of the anterior fontanel.
Ultrasound.

18. OP Position
• Labor is often prolonged and there is an increased incidence of operative vaginal
delivery, cesarean delivery, and anal sphincter lacerations.
• Mode of Delivery:
1) Spontaneous Delivery (45%).
2) Manual Rotation:
a. Flex the fetal head placing a hand in the posterior pelvis behind the occiput.
b. Apply rotatory force, the rotation should be attempted at the same time as a contraction.
3) Operative vaginal delivery:
 OP is not itself an indication for operative vaginal delivery.

19. Face Presentation
• The head is hyperextended so the occiput is in contact with the fetal back.
• 1 in 500 labours.
• Presenting part: Face.
• Diameter: Subhmento-bregmatic (9.5cm).
• Risk factors:
 Fetus is large or the pelvis is contracted.
 Enlargement of the neck.
 coils of cord around the neck
 Anencephalic

20. Face Presentation
• Diagnosis: vaginal examination.
• The mouth, nose, and the malar prominences may be palpated.
• Mode of Delivery:
The fetus must rotate to a mentum anterior position → Spontaneous vaginal delivery / Forceps
Persistent mentum posterior → cesarean delivery.
Vacuum extractor is absolutely contraindicated.

21. Brow Presentation
• The portion of the fetal head between the orbital ridge and the anterior
fontanel presents at the pelvic inlet.
• occurring in 1 in 2,000 labours
• Diameter: Occipito-mental (13cm).
• Diagnosis: vaginal examination.
• The frontal sutures, anterior fontanel, orbital ridges, eyes, and root of the nose may
be felt.
• Mode of Delivery:
 If it converts to vertex or face → according to their respective mechanisms.
 Persistent brow → cesarean delivery.

22. Breech Presentation
• Most commonly encountered malpresentation and occurs in 3–4% of
term pregnancies, but is more common at earlier gestations.
• Types:
Frank/Extended:
 thighs flexed
 legs extended
Complete/Flexed:
 thighs and legs flexed
Footling/Incomplete:
 thighs and knees extended
 foot presents at the cervix

23. Breech Presentation
• Predisposing factors:
Fetal/placental
 Multiple gestation.
 Prematurity.
 Placenta previa.
 Abnormality (e.g. anencephaly or hydrocephalus).
 Fetal neuromuscular condition.
 Oligohydramnios.
 Polyhydramnios.:
Maternal:
Fibroids.
Congenital uterine abnormalities
(e.g. bicornuate uterus).
Uterine surgery.

24. Breech Presentation
• Prenatal Management:
• If a breech presentation is clinically suspected at or after 36 weeks:
 Fetal biometry
 Amniotic fluid volume
 Placental site
 Position of the fetal legs
 Any anomalies previously undetected
• Mode of Delivery:
1) Elective caesarean section (best method)
2) External cephalic version (ECV)
3) Vaginal breech delivery

25. Breech Presentation
• External cephalic version:
• procedure is performed at or after 37 completed weeks’ gestation.
• Performed with a tocolytic (e.g. nifedipine).
• Success rates 50% (experience, multiparous women).
• Mildly uncomfortable for the mother.
• Should last no more than 10 mints.
• A fetal heart rate trace must be performed before and after the procedure.
• Rh- → anti-D.

26. Breech Presentation
• External cephalic version: (Contraindications)
• Fetal abnormality (e.g. hydrocephalus).
• Placenta previa.
• Oligohydramnios or polyhydramnios.
• History of antepartum hemorrhage.
• Previous caesarean or myomectomy scar on the uterus.
• Multiple gestation.
• Pre-eclampsia or hypertension.
• Plan to deliver by caesarean section anyway.

27. Breech Presentation
• External cephalic version: (Complications)
• Placental abruption.
• Premature rupture of the membranes.
• Cord accident.
• Transplacental hemorrhage.
• Fetal bradycardia or decelerations, usually transient and self‐limited

28. Breech Presentation
• External cephalic version: (Technique)
Elevate breech with
suprapubic hand
Push breech into iliac fossa
while flexes fetal head

29. Breech Presentation
• External cephalic version: (Technique)
fetus becomes
transverse lie
The fetal heart rate should be
checked after the external
version has been completed

30. Breech Presentation
• Vaginal breech delivery: (Pre-requisites)
• The presentation should be either extended/frank or flexed/complete (but feet not below the
fetal buttocks).
• No evidence of feto-pelvic disproportion.
• Estimated fetal weight of <3,500 g.
• No evidence of hyperextension of the fetal head.
• No fetal abnormalities (e.g. severe hydrocephalus).
• Operating room accessibility (for urgent cesarean delivery).

31. Breech Presentation
• Vaginal breech delivery: (Technique)
1) Delivery of the buttocks:
Deliver spontaneously
2) Delivery of the legs and lower body:
Pinard’s maneuver

32. Breech Presentation
• Vaginal breech delivery:
(Technique)
3) Delivery of the shoulders:
Loveset’s maneuver.

33. Breech Presentation
• Vaginal breech delivery:
(Technique)
4) Delivery of the head:
Modified Mauriceau‐
Smellie‐Veit (MSV) Maneuver

34. Breech Presentation
• Vaginal breech delivery: (Complications)
• Nuchal arm(s)
• Head entrapment
• Umbilical cord prolapse

35. Other fetal malpresentations
• Transverse Lie or Shoulder Presentation: (Causes)
• Unusual relaxation of the abdominal wall
• Preterm fetus
• Placenta previa
• Abnormal uterus
• Contracted pelvis
• Tumor occluding the birth canal
• Polyhydramnios

36. Other fetal malpresentations
• Transverse Lie or Shoulder Presentation:
• Incidence: occurring in 1 in 300 pregnancies.
• Diagnosis: Vaginal examination.
• Mode of Delivery:
• Spontaneous birth in transverse lie is impossible.
• Cesarean delivery is mandatory in most cases.
• Before the onset of labor or in early labor with intact membranes → attempt ECV.

37. Other fetal malpresentations
• Compound Presentation:
• Often no cause is found.
• More common with premature infants.
• Diagnosis: Vaginal examination.
• Mode of Delivery:
• Most commonly the prolapsed limb will deliver spontaneously along with the head, or sometimes the
fetus will retract its limb spontaneously.
• If the prolapsed arm appears to be impeding descent, it should be gently elevated upward.
• Occasionally cesarean delivery will be necessary.