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Malpresentations

Shrooti shah
M.Sc. Nursing
Maternal Health Nursing
Batch 2011
Malpresentations
1. Face presentation
2. Brow presentation

3. Breech presentation
4. Shoulder presentation

5. Unstable lie

#
Face presentation
#
Introduction
• When the attitude of the head is one of complete
extension, the occiput of the fetus will be in contact with its
spine and the face will be present.
• The incidence is about 1:500
• Types:
 Primary face presentation
 Secondary face presentation

#
Six positions in face presentation
• Right mentoposterior
• Left mentoposterior
• Right mentolateral
• Left mentolateral
• Right mentoanterior
• Left mentoanterior

#
Denominator and presenting diameter
• The denominator is the mentum
• The presenting diameters are the submentobregmatic (9.5cm)
and the bitemporal (8.2cm)

#
Causes
• Anterior obliquity of the uterus

• Contracted pelvis
• Polyhydraminos

• Congenital abnormality: Anencephaly

#
Antenatal diagnosis
• Antenatal diagnosis is rare since face presentation develops
during labour in the majority of the cases.
•

A cephalic presentation in a known anencephalic fetus
may be presumed to be a face presentation.

#
Intrapartum diagnosis
On abdominal palpation
• Face presentation may not be detected, especially if the
mentum is anterior. The occiput feels prominent, with a
groove between head and back. But it may be mistaken for
the sinciput.
• The limbs may be palpated on the side opposite to the
occiput
•

The fetal heart is best heard through the fetal chest on the
same side as the limbs.

•

In the mentoposterior position the fetal heart is difficult to
hear because the fetal chest is in contact with the maternal
#
spine.
On abdominal palpation

#
On vaginal examination
• The presenting part is high, soft and irregular. When the
cervix is sufficiently dilated, the orbital ridges, eyes, nose
and mouth may be felt.

#
On vaginal examination
• As
labour
progresses
the
face
becomes
oedematous, making it more difficult to distinguish from a
breech presentation.
• To determine position the mentum must be located; if it is
posterior, the midwife should decide whether it is lower
than the sinciput; if so, it will rotate forwards if it can
advance.
• In a left mentoanterior position, the orbital ridges will be in
the left oblique diameter of the pelvis.

#
Mechanism of left mentoanterior
position
• The lie is longitudinal
• The attitude is one of extension of head and back
• The presentation is face
• The position is left mentoanterior
• The denominator is the mentum
• The presenting part is the left malar bone

#
Mechanism cont…
• Extension: descent takes place with increasing extension.
The mentum becomes the leading part.
• Internal rotation of the head: this occurs when the chin
escapes under the symphysis pubis.
• Flexion: this takes place and the sinciput, vertex and
occiput sweep the perineum; the head is born.
• Restitution; this occurs when the chin turns 1/8 of a circle
to the woman’s left
#
Mechanism cont…

#
Mechanism cont…
• Internal rotation of the shoulders: the shoulders enter the
pelvis in the left oblique diameter and the anterior shoulder
reaches the pelvic floor first and rotates forwards 1/8 of a
circle along the right side of the pelvis.

• External rotation of the head: this occurs simultaneously.
The chin moves a further 1/8 of a circle to the left.
• Lateral flexion: the anterior shoulder escapes under the
symphysis pubis, the posterior shoulder sweeps the
perineum and the body is born by a movement of lateral
flexion.
#
Possible course and outcomes of
labour
Prolonged labour:
• labour is often prolonged because the face is an ill-fitting
presenting part and does not therefore stimulate effective
uterine contractions.

•

In addition the facial bones do not mould.

• The fetal axis pressure is directed to the chin and the head
is extended and almost at right angles to the
spine, increasing the diameters to accommodate in the
pelvis.

#
Possible course and outcomes of
labour
• Mentoanterior
positions:
with
good
uterine
contractions, descent and rotation of the head occur and
labour progresses to a spontaneous delivery.

• Mentoposterior positions: if the head is completely
extended, so that the mentum reaches the pelvic floor
first, and the contractions are effective, the mentum will
rotate forwards and the position becomes anterior.

#
Possible course and outcome…
Persistent mentoposterior positions
• in this case the head is incompletely extended and the
sinciput reaches the pelvic floor first and rotates forwards
1/8 of a circle, which brings the chin into the hollow of the
sacrum. There is no further mechanism.

#
Persistent mentoposterior positions
• The face becomes impacted because, in order to descend
further, both head and chest would have to be accommodated
in the pelvis.
• Whatever emerges anteriorly from the vagina must pivot
around the subpubic arch; if the chin is posterior this is
impossible because the head can extend no further.

#
Possible course and outcome…
Reversal of face presentation
• A face presentation in a persistent mentoposterior position
may in some cases, be manipulated to an occipitioanterior
position using bimanual pressure.

• This method was developed to reduce the likelihood of an
operative delivery for those women who refused caesarean
section

#
First stage
• Routine observations of maternal and fetal conditions.

• Immediately following rupture of the membranes, a vaginal
examination should be performed.
• Descent of the head should be observed abdominally.
• In mentoposterior position: It is to noted that whether the
mentum is lower than the sinciput, since rotation and
descent depends on this. If the head remains high in spite of
good contractions, caesarean section is likely.

#
Birth of the head
• When the face appears at the vulva, extension must be
maintained by holding back the sinciput and permitting the
mentum to escape under the symphysis pubis before the
occiput is allowed to sweep the perineum.
•

In this way the submentovertical diameter (11.5cm)
instead of the mentovertical diameter (13.5cm) distends the
vaginal orifice.

• Because the perineum is also distended by the biparietal
diameter (9.5cm), an elective episiotomy may be
performed to avoid extensive lacerations.

#
Birth of the head

#
Birth of head
• If the head does not descend in the second stage, the doctor
should be informed.
• In a mentoanteror position it may be possible for the
obstetrician to deliver the baby with forceps; when rotation
is incomplete, or the position remains mentoposterior, a
rotational forceps delivery may be feasible. If the head has
become impacted, or there is any suspicion of
disproportion, a caesarean section will be necessary.

#
Complications
• Obstructed labour

• Cord prolapse
• Facial bruising

• Cerebral haemorrhage

#
Brow presentation

#
Brow presentation
• In the brow presentation the fetal head is partially extended

with the frontal bone, which is bounded by the anterior
fontanelle and the orbital ridges, lying at the pelvic brim.

• The

presenting

diameter

of

13.5

cm

is

the

mentovertical, which exceeds all diameter in an average-

size pelvis.
• This presentation is rare, with an incidence of approximately

1 in 1000 deliveries
#
Diameter of brow presentation

#
Causes of brow presentation
• During the process of extension fro a vertex presentation to
a face presentation, the brow will present temporarily and
in a few cases this will persist.

#
Diagnosis of brow presentation
• Brow presentation is not usually detected before the onset
of labour.
On abdominal palpation
• The head is high, appears unduly large and does not
descend into the pelvis despite good uterine contractions.

#
Diagnosis of brow presentation
On vaginal examination
• The presenting part is high and may be difficult to reach.
• The anterior fontanelle may be felt on one side of the
pelvis and the orbital ridges, and possibly the root of the
nose, and at the other.
• A large caput succedaneum may mask these landmark if
the woman has been in labour for some hours.

#
Management of brow presentation
• The doctor must be informed immediately this presentation
is suspected. This is because vaginal delivery is extremely
rare and obstructed labour usually results.
• It is possible that a woman with a large pelvis and a small
may deliver vaginally.
• When the brow reaches the pelvic floor the maxilla rotates
forwards and the head is born by a mechanism somewhat
similar to that of a persistent occipito posterior position.
However, the midwife should never expect such a
favourable outcome.
#
Management of brow presentation
• If there is no evidence of fetal compromise, the doctor
may allow labour to continue for a short while in case
further extension of the head converts the brow
presentation to a face presentation.
• If the head fails to descend and the brow presentation
persists, a caesarean section is performed with
maternal consent.

#
Complications of brow presentation
• These are the same as in a face presentation, except that
obstructed labour requiring caesarean section is the
probable rather than a possible outcome.

#
Shoulder presentation
• When the fetus lies with its long axis across the long axis of
the uterus (transverse lie) the shoulder is most likely to
present. Occasionally the lie is oblique but this does not
persist as the uterine contractions during labour make it
longitudinal or transverse.
• Shoulder presentation
pregnancies near term.
•

occurs

in

approximately

1:300

Only 17% of these cases remain as a transverse lie at the
onset of labour; the majority are multigravidae.

#
Shoulder presentation

#
Causes of Shoulder presentation
Maternal
• Lax abdominal and uterine muscles
• Uterine abnormality
• Contracted pelvis
Fetal
• Pre-term pregnancy
• Multiple pregnancy
• Polyhydramnios
• Macerated fetus
• Placenta praevia
#
Antenatal diagnosis
On abdominal palpation
• The uterus appears broad and the fundal height is less than
expected for the period of gestation.
• On pelvic and fundal palpation, neither head nor breech is
felt.
• The mobile head is found on one side of the abdomen and
the breech at a slightly higher level on the other.
Ultrasound
• An ultrasound scan may be used to confirm the lie and
presentation.
#
Intrapartum diagnosis
On abdominal palpation
1. The findings are as above but when the membranes have
ruptured the irregular outline of the uterus is more
marked.
2. If the uterus is contracting strongly and becomes moulded
around the fetus, palpation is very difficult.
3. The pelvis is no longer empty, the shoulder being wedged
into it.

#
On vaginal examination
• The membranes usually rupture early because of the illfitting presenting part, with a high risk of cord prolapse.
• If the labour has been in progress for some time the
shoulder may be felt as a soft irregularmass. It is
sometimes possible to palpate the ribs, their characteristic
grid-iron pattern being diagnostic.

#
On vaginal examination
• When the shoulder enters the pelvic brim an arm may
prolapse; this should be differentiated from a leg. The
hand is not at right angles to the arm, the fingers are
longer than toes and of unequal length and the thumb
can be opposed.
• No os calcis can be felt and the palm is shorter than
the sole. If the arm is flexed, an elbow feels sharper
than a knee.

#
Possible outcome
• There is no mechanism for delivery of a shoulder
presentation.
• If this persists in labour, delivery must be by caesarean
section to avoid obstructed labour and subsequent uterine
rupture.
• Whenever the midwife detects a transverse lie she must
obtain medical assistance.

#
Management
Antenatal
• A cause must be sought before deciding on a
course of management.
– Ultrasound examination
– X-ray pelvimetry will demonstrate a contracted pelvis.

• According to the cause elective caesarean section
may be required.

#
Intrapartum
• If a transverse lie is detected in early labour while the
membranes are still intact, the doctor may attempt an
ECV, followed, if this is successful, by a controlled rupture of
the membranes.(Hofmeyr & Hutton 2006).

• If the membranes have already ruptured spontaneously, a
vaginal examination must be performed immediately to
detect possible cord prolapse.
Immediate caesarean section must be performed:
• if the cord prolapses
• when the membranes are already ruptured
• when ECV is unsuccessful
• when labour has already been in progress for some hours.
#
Complications
1. Prolapsed cord
2. Prolapsed arm
3. Neglected shoulder presentation

#
Treatment
• An immediate caesarean section is performed under
general anaesthetic regardless of whether the fetus is
alive or dead, as attempts at manipulative procedures
or destructive operations can be dangerous for the
mother and may result in uterine rupture.

#
Unstable lie
• The lie is defined as unstable when after 36 weeks’
gestation, instead of remaining longitudinal, it varies from
one examination to another between longitudinal and
oblique or transverse.

Causes
Maternal
• lax uterine muscles in multigravidae
• contracted pelvis.
Fetal
• polyhydramnios
• placenta praevia.

#
Management
Antenatal
• It may be advisable for the woman to be admitted to
hospital.
• An alternative is for the woman to admit herself to the
labour ward as soon as labour commences.
• The risk associated with the possibility of rupture of
membranes and cord prolapse should be emphasized if the
mother chooses to remain at home.
• Ultrasonography is used to rule out placenta praevia.
• Attempts will be made to correct the abnormal presentation
by ECV.
• If unsuccessful, caesarean section is considered.
#
Intrapartum
• Many obstetricians induce labour after 38 weeks’
gestation, having first ensured that the lie is longitudinal;
the induction may be performed by commencing an
intravenous infusion of oxytocin to stimulate contractions.
• A controlled rupture of the membranes is performed so
that the head enters the pelvis.

#
Intrapartum…
• The midwife should ensure that the woman has an
empty rectum and bladder before the procedure, as a
loaded rectum or full bladder can prevent the
presenting part from entering the pelvis.

• She should palpate the abdomen at frequent intervals
to ensure that the lie remains longitudinal and to
assess the descent of the head.
• Labour is regarded as a trial.

#
Complications
• If labour commences with the lie other than
longitudinal, the complications are the same as for a
transverse lie.

#
Compound presentation
• When a hand, or occasionally a foot, lies alongside the
head, the presentation is said to be compound.
• This tends to occur with a small fetus or roomy pelvis and
seldom is difficulty encountered except in cases where it is
associated with a flat pelvis.
• On rare occasions the head, hand and foot are felt in the
vagina – a serious situation that may occur with a dead
fetus.

#
Compound presentation
• If diagnosed during the first
labour, medical aid must be sought.

stage

of

• If, during the second stage, the midwife sees a
hand presenting alongside the vertex, she could try
to hold the hand back.

#
Breech presentation
• A breech presentation is an unusual presentation but it
should not be considered abnormal as the fetus lies
longitudinally with the buttocks in the lower pole of the
uterus.

• The presenting diameter is the bitrochanteric (10cm) and
the denominator the sacrum.
• This presentation occurs in approximately 3% of
pregnancies at term.
• In mid-trimester the frequency is much higher because the
greater proportion of amniotic fluid facilitates free
movement of the fetus.
#
Positions of
breech
presentation

#
Types of
breech
presentation

#
Causes
• Extended legs
• Preterm labour
• Multiple pregnancy
• Polyhydramnios
• Hydrocephaly
• Uterine abnormalities
• Placenta praevia
#
Antenatal diagnosis
Abdominal examination
• Listen to the mother

Palpation
• In primigravidae, diagnosis is more difficult because of
their firm abdominal muscles.
• On palpation the lie is longitudinal with a soft
presentation, which is more easily felt using Pawlik’s grip.
• The head can usually be felt in the fundus as a round hard
mass, which may be made to move independently of the
back by balloting it with one or both hands.
• If the legs are extended, the feet may prevent such
nodding.
#
Antenatal diagnosis
• Auscultation
• Ultrasound examination
– This may be used to demonstrate a breech presentation.

• X-ray examination
– Although largely superseded by ultrasound, X-ray has
the added advantage of allowing pelvimetry to be
performed at the same time.

#
Diagnosis during labour
• A previously unsuspected breech presentation may not
be diagnosed until the woman is in established labour.
• If the legs are extended, the breech may feel like a
head abdominally, and also on vaginal examination
• If the cervix is <3cm dilated and the breech is high.
Abdominal examination
• Breech presentation may be diagnosed on admission
in labour.

#
Vaginal examination

#
Management of breech presentation
• At 37 weeks’ gestation a discussion of the available
options should take place between the mother and an
experienced practitioner and a decision made as to
whether to perform an elective caesarean section or to
attempt a vaginal birth.
• A planned caesarean section at term reduces the
perinatal and neonatal mortality and morbidity but
there is an increased risk of maternal morbidity.

#
Management…
Assessment for vaginal birth
•
•
•
•

Complete or frank breech
Adequate clinical pelvimetry
Fetus not too large
No previous caesarean section or
cephalopelvic disproportion
• Flexed head

#
Mechanism of left sacroanterior position
• The lie is longitudinal
• The attitude is one of complete flexion
• The presentation is breech
• The position is left sacroanterior
• The denominator is the sacrum
• The presenting part is the anterior (left) buttock
•The bitrochanteric diameter, 10cm, enters the pelvis in
the left oblique diameter of the brim
•The sacrum points to the left iliopectineal eminence.
#
Mechanism…
Compaction
• Descent
takes
place
with
increasing
compaction, owing to increased flexion of the limbs.

Internal rotation of the buttocks
• The anterior buttock reaches the pelvic floor first and
rotates forwards 1/8 of a circle along the right side of
the pelvis to lie underneath the symphysis pubis.
• The bitrochanteric diameter is now in the
anteroposterior diameter of the outlet.
#
Mechanism…
Lateral flexion of the body
• The anterior buttock escapes under the symphysis
pubis, the posterior buttock sweeps the perineum and
the buttocks are born by a movement of lateral
flexion.
Restitution of the buttocks
• The anterior buttock turns slightly to the mother’s
right side.

#
Mechanism…
Internal rotation of the shoulders
• The shoulders enter the pelvis in the same oblique
diameter as the buttocks, the left oblique.
• The anterior shoulder rotates forwards 1/8 of a circle
along the right side of the pelvis and escapes under the
symphysis pubis; the posterior shoulder sweeps the
perineum and the shoulders are born.
Internal rotation of the head
• The head enters the pelvis with the sagittal suture in the
transverse diameter of the brim.
• The occiput rotates forwards along the left side and the
suboccipital region (the nape of the neck) impinges on
the undersurface of the symphysis pubis.
#
Mechanism…
External rotation of the body
• At the same time the body turns so that the back is
uppermost.

Birth of the head
• The chin, face and sinciput sweep the perineum and
the head is born in a flexed attitude.

#
Management of First stage
• Basic care during this stage is the same as in normal
labour encouraging upright positions a much as
possible to aid descent of the presenting part.

• The breech with extended legs fits the cervix quite
well, the complete breech is a less well-fitting
presenting part and the membranes tend to rupture
early.
• For this reason there is an increased risk of cord
prolapse, and a vaginal examination is performed to
exclude this as soon as the membranes rupture.
#
Management of first stage
• If they do not rupture spontaneously at an early
stage, it is considered safer to leave them intact
until labour is well established and the breech is at
the level of the ischial spines.
• Meconium-stained liquor is sometimes found
owing to compression of the fetal abdomen and is
not always a sign of fetal compromise.

#
Management of Second stage
• Full dilatation of the cervix should always be
confirmed by vaginal examination before the woman
commences active pushing.

• The woman may like to adopt a supported squat to
utilize gravity in the second stage.
• If the birth is taking place in hospital it is usual to
inform the obstetrician of the onset of the second
stage; a paediatrician should be present for the birth
and it is usual to inform the anaesthetist also in case a
general anaesthetic is required.
#
Management of second stage…
• Active pushing is not commenced until the
buttocks are distending the vulva.
• Failure of the breech to descend onto the perineum
in the second stage despite good contractions may
indicate a need for caesarean section.

#
Types of birth
Spontaneous
• The birth occurs with little assistance from the
attendant.

Assisted breech
• The buttocks are born spontaneously, but some
assistance is necessary for delivery of extended
legs or arms and the head.
Breech extraction
• This is a manipulative delivery carried out by an
obstetrician and is performed to hasten the birth in
#
Management of the birth
• A woman who has chosen to birth vaginally needs
support from skilled and confident midwives.
• An explanation is given to the woman so that she can
understand the importance of not pushing until full
dilatation of her cervix has been confirmed.
• The woman is encouraged to push with the
contractions and the buttocks are born spontaneously.
• If the legs are flexed, the feet disengage at the vulva
and the baby is born as far as the umbilicus
#
Management of birth
• A loop of cord is gently pulled down to avoid
traction on the umbilicus.
• The midwife should feel for the elbows, which are
usually on the chest. If so, the arms will escape
with the next contraction.

• If the arms are not felt, they are extended.
• Episiotomy is to be performed.
#
Birth of the shoulders
• The uterine contractions and the weight of the body
will bring the shoulders down on to the pelvic floor
where they will rotate into the anteroposterior
diameter of the outlet.
• It is helpful to wrap a small towel around the baby’s
hips.

• The midwife now grasps the baby by the iliac crests
with her thumbs held parallel over his sacrum and tilts
the baby towards the maternal sacrum in order to free
the anterior shoulder.
#
Birth of the shoulders
• When the anterior shoulder has escaped, the
buttocks are lifted towards the mother’s abdomen
to enable the posterior shoulder and arm to pass
over the perineum .

• As the shoulders are born, the head enters the
pelvic brim and descends through the pelvis with
#
the sagittal suture in the transverse diameter.
Birth of the shoulders
• The back must remain lateral until this has
happened but will afterwards be turned uppermost.
• If the back is turned upwards too soon, the
anteroposterior diameter of the head will enter the
anteroposterior diameter of the brim and may
become extended.
• The shoulders may then become impacted at the
outlet and the extended head may cause difficulty.
#
Birth of the head
• When the back has been turned the infant is allowed to
hang from the vulva without support.
• The baby’s weight brings the head onto the pelvic floor
on which the occiput rotates forwards.

• The sagittal suture is now in the anteroposterior diameter
of the outlet.
• If rotation of the head fails to take place, two fingers
should be placed on the malar bones and the head
rotated. The baby can be allowed to hang for 1 or 2min.
• Gradually the neck elongates, the hair-line appears and
the suboccipital region can be felt.
#
Birth of the head
• Forceps delivery: Most breech deliveries are
performed by an obstetrician, who will apply
forceps to the after-coming head to achieve a
controlled birth.
• Burns Marshall method

#
Mauriceau- SmellieVeit maneouvre

#
Delivery for extended legs

#
Delivery for Extended arms

#
Lovset maneouvre
• Hold baby by hips, turn half circle, keep back
uppermost, apply downward traction to allow
posterior arm to become anterior and deliver under
pubic arch.
• Assist delivery of arm; place finger(s) on upper
arm, draw arm down over chest as elbow
flexed, allow hand to sweep over face.
• Deliver second arm; turn baby back half
circle, keep back uppermost, apply downward
#
traction, deliver second arm under pubic arch
Lovset maneouvre

#
Delivery of arms
If baby’s body cannot be turned to deliver anterior
arm first, deliver posterior shoulder
– Hold and lift baby up by ankles
– Move chest towards woman’s inner leg; shoulder
that is posterior should deliver
– Deliver arm and hand
– Lay baby down by ankles; shoulder that is anterior
should deliver
– Deliver arm and hand
#
Delivery of posterior shoulder

#
Delivery of the extended head
• If, when the body has been allowed to hang, the neck
and hair-line are not visible, it is probable that the
head is extended.
• This may be dealt with by the use of forceps or the
Mauriceau– Smellie–Veit manoeuvre.
• If the head is trapped in an incompletely dilated
cervix, an air channel can be created to enable the
baby to breathe pending intervention.

• This is done by inserting two fingers or a Sim’s
speculum in front of the baby’s face and holding the
#
vaginal wall away from the nose.
Delivery of the extended head
• Moisture is mopped away and the airways are
cleared.
• Attempts to release the head from the cervix result
in high fetal morbidity and mortality.
• The McRoberts manoeuvre has been suggested as
a method to facilitate the release of the fetal head.
• The McRoberts manoeuvre requires the woman to
lie flat on her back and bring her knees up to her
abdomen with hips abducted.
#
Indications for cesarean delivery
•
•
•
•
•
•
•
•

•
•

A large fetus
Any degree of contraction
A hyperextended head
When delivery is indicated in the absence of spontaneous
labor
Uterine dysfunction
Incomplete or footling breech presentation
Severe fetal-growth restriction
Previous perinatal death or children suffering from birth
trauma
A request for sterilization
Lack of an experienced operator.
#
Complications
• Impacted breech
• Cord prolapse
• Birth injury
• Superficial tissue damage

• Fractures of humerus, clavicle or femur or
dislocation of shoulder or hip
• Erb’s palsy
#
Complications
• Trauma to internal organs:
–
–
–
–

A ruptured liver or spleen, may be produced by
grasping the abdomen.
Damage to the adrenals
Spinal cord damage or fracture of the spine

• Intracranial haemorrhage
• Fetal hypoxia
• Premature separation of the placenta
• Maternal trauma

#
References
1. Dutta D.C. Textbook of obstetrics. Sixth edition.
Calcutta, India; New Central Book agency (P) Ltd: 2004.
2. Arulkumaran SS, Arjun G. The management of labour.
Third edition. India; University Press: 2011
3. Cunningham, Leveno, Bloom etal. William’s obstetrics.
23rd edition. United states of America; McGraw Hill
companies: 2010.
4. Fraser DM, Cooper MA. Myles Textbook of Midwives.
Fourteenth edition. Edinburgh; Churchill Livingstone:
2003.
5. Jacob A. A comprehensive textbook of midwifery.
Second edition. India; Jaypee Brothers Medical publishers
#
(P) ltd.
#

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Malpresentations

  • 2. Malpresentations 1. Face presentation 2. Brow presentation 3. Breech presentation 4. Shoulder presentation 5. Unstable lie #
  • 4. Introduction • When the attitude of the head is one of complete extension, the occiput of the fetus will be in contact with its spine and the face will be present. • The incidence is about 1:500 • Types:  Primary face presentation  Secondary face presentation #
  • 5. Six positions in face presentation • Right mentoposterior • Left mentoposterior • Right mentolateral • Left mentolateral • Right mentoanterior • Left mentoanterior #
  • 6. Denominator and presenting diameter • The denominator is the mentum • The presenting diameters are the submentobregmatic (9.5cm) and the bitemporal (8.2cm) #
  • 7. Causes • Anterior obliquity of the uterus • Contracted pelvis • Polyhydraminos • Congenital abnormality: Anencephaly #
  • 8. Antenatal diagnosis • Antenatal diagnosis is rare since face presentation develops during labour in the majority of the cases. • A cephalic presentation in a known anencephalic fetus may be presumed to be a face presentation. #
  • 9. Intrapartum diagnosis On abdominal palpation • Face presentation may not be detected, especially if the mentum is anterior. The occiput feels prominent, with a groove between head and back. But it may be mistaken for the sinciput. • The limbs may be palpated on the side opposite to the occiput • The fetal heart is best heard through the fetal chest on the same side as the limbs. • In the mentoposterior position the fetal heart is difficult to hear because the fetal chest is in contact with the maternal # spine.
  • 11. On vaginal examination • The presenting part is high, soft and irregular. When the cervix is sufficiently dilated, the orbital ridges, eyes, nose and mouth may be felt. #
  • 12. On vaginal examination • As labour progresses the face becomes oedematous, making it more difficult to distinguish from a breech presentation. • To determine position the mentum must be located; if it is posterior, the midwife should decide whether it is lower than the sinciput; if so, it will rotate forwards if it can advance. • In a left mentoanterior position, the orbital ridges will be in the left oblique diameter of the pelvis. #
  • 13. Mechanism of left mentoanterior position • The lie is longitudinal • The attitude is one of extension of head and back • The presentation is face • The position is left mentoanterior • The denominator is the mentum • The presenting part is the left malar bone #
  • 14. Mechanism cont… • Extension: descent takes place with increasing extension. The mentum becomes the leading part. • Internal rotation of the head: this occurs when the chin escapes under the symphysis pubis. • Flexion: this takes place and the sinciput, vertex and occiput sweep the perineum; the head is born. • Restitution; this occurs when the chin turns 1/8 of a circle to the woman’s left #
  • 16. Mechanism cont… • Internal rotation of the shoulders: the shoulders enter the pelvis in the left oblique diameter and the anterior shoulder reaches the pelvic floor first and rotates forwards 1/8 of a circle along the right side of the pelvis. • External rotation of the head: this occurs simultaneously. The chin moves a further 1/8 of a circle to the left. • Lateral flexion: the anterior shoulder escapes under the symphysis pubis, the posterior shoulder sweeps the perineum and the body is born by a movement of lateral flexion. #
  • 17. Possible course and outcomes of labour Prolonged labour: • labour is often prolonged because the face is an ill-fitting presenting part and does not therefore stimulate effective uterine contractions. • In addition the facial bones do not mould. • The fetal axis pressure is directed to the chin and the head is extended and almost at right angles to the spine, increasing the diameters to accommodate in the pelvis. #
  • 18. Possible course and outcomes of labour • Mentoanterior positions: with good uterine contractions, descent and rotation of the head occur and labour progresses to a spontaneous delivery. • Mentoposterior positions: if the head is completely extended, so that the mentum reaches the pelvic floor first, and the contractions are effective, the mentum will rotate forwards and the position becomes anterior. #
  • 19. Possible course and outcome… Persistent mentoposterior positions • in this case the head is incompletely extended and the sinciput reaches the pelvic floor first and rotates forwards 1/8 of a circle, which brings the chin into the hollow of the sacrum. There is no further mechanism. #
  • 20. Persistent mentoposterior positions • The face becomes impacted because, in order to descend further, both head and chest would have to be accommodated in the pelvis. • Whatever emerges anteriorly from the vagina must pivot around the subpubic arch; if the chin is posterior this is impossible because the head can extend no further. #
  • 21. Possible course and outcome… Reversal of face presentation • A face presentation in a persistent mentoposterior position may in some cases, be manipulated to an occipitioanterior position using bimanual pressure. • This method was developed to reduce the likelihood of an operative delivery for those women who refused caesarean section #
  • 22. First stage • Routine observations of maternal and fetal conditions. • Immediately following rupture of the membranes, a vaginal examination should be performed. • Descent of the head should be observed abdominally. • In mentoposterior position: It is to noted that whether the mentum is lower than the sinciput, since rotation and descent depends on this. If the head remains high in spite of good contractions, caesarean section is likely. #
  • 23. Birth of the head • When the face appears at the vulva, extension must be maintained by holding back the sinciput and permitting the mentum to escape under the symphysis pubis before the occiput is allowed to sweep the perineum. • In this way the submentovertical diameter (11.5cm) instead of the mentovertical diameter (13.5cm) distends the vaginal orifice. • Because the perineum is also distended by the biparietal diameter (9.5cm), an elective episiotomy may be performed to avoid extensive lacerations. #
  • 24. Birth of the head #
  • 25. Birth of head • If the head does not descend in the second stage, the doctor should be informed. • In a mentoanteror position it may be possible for the obstetrician to deliver the baby with forceps; when rotation is incomplete, or the position remains mentoposterior, a rotational forceps delivery may be feasible. If the head has become impacted, or there is any suspicion of disproportion, a caesarean section will be necessary. #
  • 26. Complications • Obstructed labour • Cord prolapse • Facial bruising • Cerebral haemorrhage #
  • 28. Brow presentation • In the brow presentation the fetal head is partially extended with the frontal bone, which is bounded by the anterior fontanelle and the orbital ridges, lying at the pelvic brim. • The presenting diameter of 13.5 cm is the mentovertical, which exceeds all diameter in an average- size pelvis. • This presentation is rare, with an incidence of approximately 1 in 1000 deliveries #
  • 29. Diameter of brow presentation #
  • 30. Causes of brow presentation • During the process of extension fro a vertex presentation to a face presentation, the brow will present temporarily and in a few cases this will persist. #
  • 31. Diagnosis of brow presentation • Brow presentation is not usually detected before the onset of labour. On abdominal palpation • The head is high, appears unduly large and does not descend into the pelvis despite good uterine contractions. #
  • 32. Diagnosis of brow presentation On vaginal examination • The presenting part is high and may be difficult to reach. • The anterior fontanelle may be felt on one side of the pelvis and the orbital ridges, and possibly the root of the nose, and at the other. • A large caput succedaneum may mask these landmark if the woman has been in labour for some hours. #
  • 33. Management of brow presentation • The doctor must be informed immediately this presentation is suspected. This is because vaginal delivery is extremely rare and obstructed labour usually results. • It is possible that a woman with a large pelvis and a small may deliver vaginally. • When the brow reaches the pelvic floor the maxilla rotates forwards and the head is born by a mechanism somewhat similar to that of a persistent occipito posterior position. However, the midwife should never expect such a favourable outcome. #
  • 34. Management of brow presentation • If there is no evidence of fetal compromise, the doctor may allow labour to continue for a short while in case further extension of the head converts the brow presentation to a face presentation. • If the head fails to descend and the brow presentation persists, a caesarean section is performed with maternal consent. #
  • 35. Complications of brow presentation • These are the same as in a face presentation, except that obstructed labour requiring caesarean section is the probable rather than a possible outcome. #
  • 36. Shoulder presentation • When the fetus lies with its long axis across the long axis of the uterus (transverse lie) the shoulder is most likely to present. Occasionally the lie is oblique but this does not persist as the uterine contractions during labour make it longitudinal or transverse. • Shoulder presentation pregnancies near term. • occurs in approximately 1:300 Only 17% of these cases remain as a transverse lie at the onset of labour; the majority are multigravidae. #
  • 38. Causes of Shoulder presentation Maternal • Lax abdominal and uterine muscles • Uterine abnormality • Contracted pelvis Fetal • Pre-term pregnancy • Multiple pregnancy • Polyhydramnios • Macerated fetus • Placenta praevia #
  • 39. Antenatal diagnosis On abdominal palpation • The uterus appears broad and the fundal height is less than expected for the period of gestation. • On pelvic and fundal palpation, neither head nor breech is felt. • The mobile head is found on one side of the abdomen and the breech at a slightly higher level on the other. Ultrasound • An ultrasound scan may be used to confirm the lie and presentation. #
  • 40. Intrapartum diagnosis On abdominal palpation 1. The findings are as above but when the membranes have ruptured the irregular outline of the uterus is more marked. 2. If the uterus is contracting strongly and becomes moulded around the fetus, palpation is very difficult. 3. The pelvis is no longer empty, the shoulder being wedged into it. #
  • 41. On vaginal examination • The membranes usually rupture early because of the illfitting presenting part, with a high risk of cord prolapse. • If the labour has been in progress for some time the shoulder may be felt as a soft irregularmass. It is sometimes possible to palpate the ribs, their characteristic grid-iron pattern being diagnostic. #
  • 42. On vaginal examination • When the shoulder enters the pelvic brim an arm may prolapse; this should be differentiated from a leg. The hand is not at right angles to the arm, the fingers are longer than toes and of unequal length and the thumb can be opposed. • No os calcis can be felt and the palm is shorter than the sole. If the arm is flexed, an elbow feels sharper than a knee. #
  • 43. Possible outcome • There is no mechanism for delivery of a shoulder presentation. • If this persists in labour, delivery must be by caesarean section to avoid obstructed labour and subsequent uterine rupture. • Whenever the midwife detects a transverse lie she must obtain medical assistance. #
  • 44. Management Antenatal • A cause must be sought before deciding on a course of management. – Ultrasound examination – X-ray pelvimetry will demonstrate a contracted pelvis. • According to the cause elective caesarean section may be required. #
  • 45. Intrapartum • If a transverse lie is detected in early labour while the membranes are still intact, the doctor may attempt an ECV, followed, if this is successful, by a controlled rupture of the membranes.(Hofmeyr & Hutton 2006). • If the membranes have already ruptured spontaneously, a vaginal examination must be performed immediately to detect possible cord prolapse. Immediate caesarean section must be performed: • if the cord prolapses • when the membranes are already ruptured • when ECV is unsuccessful • when labour has already been in progress for some hours. #
  • 46. Complications 1. Prolapsed cord 2. Prolapsed arm 3. Neglected shoulder presentation #
  • 47. Treatment • An immediate caesarean section is performed under general anaesthetic regardless of whether the fetus is alive or dead, as attempts at manipulative procedures or destructive operations can be dangerous for the mother and may result in uterine rupture. #
  • 48. Unstable lie • The lie is defined as unstable when after 36 weeks’ gestation, instead of remaining longitudinal, it varies from one examination to another between longitudinal and oblique or transverse. Causes Maternal • lax uterine muscles in multigravidae • contracted pelvis. Fetal • polyhydramnios • placenta praevia. #
  • 49. Management Antenatal • It may be advisable for the woman to be admitted to hospital. • An alternative is for the woman to admit herself to the labour ward as soon as labour commences. • The risk associated with the possibility of rupture of membranes and cord prolapse should be emphasized if the mother chooses to remain at home. • Ultrasonography is used to rule out placenta praevia. • Attempts will be made to correct the abnormal presentation by ECV. • If unsuccessful, caesarean section is considered. #
  • 50. Intrapartum • Many obstetricians induce labour after 38 weeks’ gestation, having first ensured that the lie is longitudinal; the induction may be performed by commencing an intravenous infusion of oxytocin to stimulate contractions. • A controlled rupture of the membranes is performed so that the head enters the pelvis. #
  • 51. Intrapartum… • The midwife should ensure that the woman has an empty rectum and bladder before the procedure, as a loaded rectum or full bladder can prevent the presenting part from entering the pelvis. • She should palpate the abdomen at frequent intervals to ensure that the lie remains longitudinal and to assess the descent of the head. • Labour is regarded as a trial. #
  • 52. Complications • If labour commences with the lie other than longitudinal, the complications are the same as for a transverse lie. #
  • 53. Compound presentation • When a hand, or occasionally a foot, lies alongside the head, the presentation is said to be compound. • This tends to occur with a small fetus or roomy pelvis and seldom is difficulty encountered except in cases where it is associated with a flat pelvis. • On rare occasions the head, hand and foot are felt in the vagina – a serious situation that may occur with a dead fetus. #
  • 54. Compound presentation • If diagnosed during the first labour, medical aid must be sought. stage of • If, during the second stage, the midwife sees a hand presenting alongside the vertex, she could try to hold the hand back. #
  • 55. Breech presentation • A breech presentation is an unusual presentation but it should not be considered abnormal as the fetus lies longitudinally with the buttocks in the lower pole of the uterus. • The presenting diameter is the bitrochanteric (10cm) and the denominator the sacrum. • This presentation occurs in approximately 3% of pregnancies at term. • In mid-trimester the frequency is much higher because the greater proportion of amniotic fluid facilitates free movement of the fetus. #
  • 58. Causes • Extended legs • Preterm labour • Multiple pregnancy • Polyhydramnios • Hydrocephaly • Uterine abnormalities • Placenta praevia #
  • 59. Antenatal diagnosis Abdominal examination • Listen to the mother Palpation • In primigravidae, diagnosis is more difficult because of their firm abdominal muscles. • On palpation the lie is longitudinal with a soft presentation, which is more easily felt using Pawlik’s grip. • The head can usually be felt in the fundus as a round hard mass, which may be made to move independently of the back by balloting it with one or both hands. • If the legs are extended, the feet may prevent such nodding. #
  • 60. Antenatal diagnosis • Auscultation • Ultrasound examination – This may be used to demonstrate a breech presentation. • X-ray examination – Although largely superseded by ultrasound, X-ray has the added advantage of allowing pelvimetry to be performed at the same time. #
  • 61. Diagnosis during labour • A previously unsuspected breech presentation may not be diagnosed until the woman is in established labour. • If the legs are extended, the breech may feel like a head abdominally, and also on vaginal examination • If the cervix is <3cm dilated and the breech is high. Abdominal examination • Breech presentation may be diagnosed on admission in labour. #
  • 63. Management of breech presentation • At 37 weeks’ gestation a discussion of the available options should take place between the mother and an experienced practitioner and a decision made as to whether to perform an elective caesarean section or to attempt a vaginal birth. • A planned caesarean section at term reduces the perinatal and neonatal mortality and morbidity but there is an increased risk of maternal morbidity. #
  • 64. Management… Assessment for vaginal birth • • • • Complete or frank breech Adequate clinical pelvimetry Fetus not too large No previous caesarean section or cephalopelvic disproportion • Flexed head #
  • 65. Mechanism of left sacroanterior position • The lie is longitudinal • The attitude is one of complete flexion • The presentation is breech • The position is left sacroanterior • The denominator is the sacrum • The presenting part is the anterior (left) buttock •The bitrochanteric diameter, 10cm, enters the pelvis in the left oblique diameter of the brim •The sacrum points to the left iliopectineal eminence. #
  • 66. Mechanism… Compaction • Descent takes place with increasing compaction, owing to increased flexion of the limbs. Internal rotation of the buttocks • The anterior buttock reaches the pelvic floor first and rotates forwards 1/8 of a circle along the right side of the pelvis to lie underneath the symphysis pubis. • The bitrochanteric diameter is now in the anteroposterior diameter of the outlet. #
  • 67. Mechanism… Lateral flexion of the body • The anterior buttock escapes under the symphysis pubis, the posterior buttock sweeps the perineum and the buttocks are born by a movement of lateral flexion. Restitution of the buttocks • The anterior buttock turns slightly to the mother’s right side. #
  • 68. Mechanism… Internal rotation of the shoulders • The shoulders enter the pelvis in the same oblique diameter as the buttocks, the left oblique. • The anterior shoulder rotates forwards 1/8 of a circle along the right side of the pelvis and escapes under the symphysis pubis; the posterior shoulder sweeps the perineum and the shoulders are born. Internal rotation of the head • The head enters the pelvis with the sagittal suture in the transverse diameter of the brim. • The occiput rotates forwards along the left side and the suboccipital region (the nape of the neck) impinges on the undersurface of the symphysis pubis. #
  • 69. Mechanism… External rotation of the body • At the same time the body turns so that the back is uppermost. Birth of the head • The chin, face and sinciput sweep the perineum and the head is born in a flexed attitude. #
  • 70. Management of First stage • Basic care during this stage is the same as in normal labour encouraging upright positions a much as possible to aid descent of the presenting part. • The breech with extended legs fits the cervix quite well, the complete breech is a less well-fitting presenting part and the membranes tend to rupture early. • For this reason there is an increased risk of cord prolapse, and a vaginal examination is performed to exclude this as soon as the membranes rupture. #
  • 71. Management of first stage • If they do not rupture spontaneously at an early stage, it is considered safer to leave them intact until labour is well established and the breech is at the level of the ischial spines. • Meconium-stained liquor is sometimes found owing to compression of the fetal abdomen and is not always a sign of fetal compromise. #
  • 72. Management of Second stage • Full dilatation of the cervix should always be confirmed by vaginal examination before the woman commences active pushing. • The woman may like to adopt a supported squat to utilize gravity in the second stage. • If the birth is taking place in hospital it is usual to inform the obstetrician of the onset of the second stage; a paediatrician should be present for the birth and it is usual to inform the anaesthetist also in case a general anaesthetic is required. #
  • 73. Management of second stage… • Active pushing is not commenced until the buttocks are distending the vulva. • Failure of the breech to descend onto the perineum in the second stage despite good contractions may indicate a need for caesarean section. #
  • 74. Types of birth Spontaneous • The birth occurs with little assistance from the attendant. Assisted breech • The buttocks are born spontaneously, but some assistance is necessary for delivery of extended legs or arms and the head. Breech extraction • This is a manipulative delivery carried out by an obstetrician and is performed to hasten the birth in #
  • 75. Management of the birth • A woman who has chosen to birth vaginally needs support from skilled and confident midwives. • An explanation is given to the woman so that she can understand the importance of not pushing until full dilatation of her cervix has been confirmed. • The woman is encouraged to push with the contractions and the buttocks are born spontaneously. • If the legs are flexed, the feet disengage at the vulva and the baby is born as far as the umbilicus #
  • 76. Management of birth • A loop of cord is gently pulled down to avoid traction on the umbilicus. • The midwife should feel for the elbows, which are usually on the chest. If so, the arms will escape with the next contraction. • If the arms are not felt, they are extended. • Episiotomy is to be performed. #
  • 77. Birth of the shoulders • The uterine contractions and the weight of the body will bring the shoulders down on to the pelvic floor where they will rotate into the anteroposterior diameter of the outlet. • It is helpful to wrap a small towel around the baby’s hips. • The midwife now grasps the baby by the iliac crests with her thumbs held parallel over his sacrum and tilts the baby towards the maternal sacrum in order to free the anterior shoulder. #
  • 78. Birth of the shoulders • When the anterior shoulder has escaped, the buttocks are lifted towards the mother’s abdomen to enable the posterior shoulder and arm to pass over the perineum . • As the shoulders are born, the head enters the pelvic brim and descends through the pelvis with # the sagittal suture in the transverse diameter.
  • 79. Birth of the shoulders • The back must remain lateral until this has happened but will afterwards be turned uppermost. • If the back is turned upwards too soon, the anteroposterior diameter of the head will enter the anteroposterior diameter of the brim and may become extended. • The shoulders may then become impacted at the outlet and the extended head may cause difficulty. #
  • 80. Birth of the head • When the back has been turned the infant is allowed to hang from the vulva without support. • The baby’s weight brings the head onto the pelvic floor on which the occiput rotates forwards. • The sagittal suture is now in the anteroposterior diameter of the outlet. • If rotation of the head fails to take place, two fingers should be placed on the malar bones and the head rotated. The baby can be allowed to hang for 1 or 2min. • Gradually the neck elongates, the hair-line appears and the suboccipital region can be felt. #
  • 81. Birth of the head • Forceps delivery: Most breech deliveries are performed by an obstetrician, who will apply forceps to the after-coming head to achieve a controlled birth. • Burns Marshall method #
  • 85. Lovset maneouvre • Hold baby by hips, turn half circle, keep back uppermost, apply downward traction to allow posterior arm to become anterior and deliver under pubic arch. • Assist delivery of arm; place finger(s) on upper arm, draw arm down over chest as elbow flexed, allow hand to sweep over face. • Deliver second arm; turn baby back half circle, keep back uppermost, apply downward # traction, deliver second arm under pubic arch
  • 87. Delivery of arms If baby’s body cannot be turned to deliver anterior arm first, deliver posterior shoulder – Hold and lift baby up by ankles – Move chest towards woman’s inner leg; shoulder that is posterior should deliver – Deliver arm and hand – Lay baby down by ankles; shoulder that is anterior should deliver – Deliver arm and hand #
  • 88. Delivery of posterior shoulder #
  • 89. Delivery of the extended head • If, when the body has been allowed to hang, the neck and hair-line are not visible, it is probable that the head is extended. • This may be dealt with by the use of forceps or the Mauriceau– Smellie–Veit manoeuvre. • If the head is trapped in an incompletely dilated cervix, an air channel can be created to enable the baby to breathe pending intervention. • This is done by inserting two fingers or a Sim’s speculum in front of the baby’s face and holding the # vaginal wall away from the nose.
  • 90. Delivery of the extended head • Moisture is mopped away and the airways are cleared. • Attempts to release the head from the cervix result in high fetal morbidity and mortality. • The McRoberts manoeuvre has been suggested as a method to facilitate the release of the fetal head. • The McRoberts manoeuvre requires the woman to lie flat on her back and bring her knees up to her abdomen with hips abducted. #
  • 91. Indications for cesarean delivery • • • • • • • • • • A large fetus Any degree of contraction A hyperextended head When delivery is indicated in the absence of spontaneous labor Uterine dysfunction Incomplete or footling breech presentation Severe fetal-growth restriction Previous perinatal death or children suffering from birth trauma A request for sterilization Lack of an experienced operator. #
  • 92. Complications • Impacted breech • Cord prolapse • Birth injury • Superficial tissue damage • Fractures of humerus, clavicle or femur or dislocation of shoulder or hip • Erb’s palsy #
  • 93. Complications • Trauma to internal organs: – – – – A ruptured liver or spleen, may be produced by grasping the abdomen. Damage to the adrenals Spinal cord damage or fracture of the spine • Intracranial haemorrhage • Fetal hypoxia • Premature separation of the placenta • Maternal trauma #
  • 94. References 1. Dutta D.C. Textbook of obstetrics. Sixth edition. Calcutta, India; New Central Book agency (P) Ltd: 2004. 2. Arulkumaran SS, Arjun G. The management of labour. Third edition. India; University Press: 2011 3. Cunningham, Leveno, Bloom etal. William’s obstetrics. 23rd edition. United states of America; McGraw Hill companies: 2010. 4. Fraser DM, Cooper MA. Myles Textbook of Midwives. Fourteenth edition. Edinburgh; Churchill Livingstone: 2003. 5. Jacob A. A comprehensive textbook of midwifery. Second edition. India; Jaypee Brothers Medical publishers # (P) ltd.
  • 95. #