Malpresentation malposition by ILI
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This document discusses various fetal malpresentations and malpositions that can occur during labor and delivery. It defines malpresentation as a non-vertex presentation such as breech, brow, or transverse lie, and malposition as positions other than occiput anterior. Common presentations and positions are described along with their diagnosis, management, and potential complications. Breech presentation management includes external cephalic version, spontaneous version, or caesarean section depending on gestational age and other risk factors. Vaginal breech delivery techniques like Pinard's maneuver and Burns Marshall method are outlined. Face presentations are also summarized.
Malpresentation malposition by ILI
- 2. DefinitionMalpresentation = Fetal presenting part other than vertex & includes breech, brow, transverse, face.Malposition = Refers to positions other than an occipito-anterior position.
- 4. Commonest Presentation & PositionSuboccipito-BregmaticExtends from center of neck to bregma.Presentation: VertexAttitude: Complete FlexionD = 9.5cm
- 6. MALPOSITIONMalpositions include occipitoposteriorand occipitotransverse positions of fetal head in relation to maternal pelvis.
- 7. How to diagnose?PalpationFetal back is found to one side or may be difficult to identified.The fetal head is posterolateral and will be free above the brim.AuscultationThe fetal heart best heard in the flank but descends to just above the pubis as the head rotates and descends.VEthe membrane tend to ruptured early before the labour is establish if the membrane is intact they may protrude through the cervix giving finger-like forewaters.
- 8. Factors that favour malpositionPendulous abdomen- in multiparaeAnthropoid pelvic brim- favours direct O.P/O.AAndroid pelvic brim A flat sacrum-transverse positionThe placenta on the ant. uterine wallR.O.P
- 9. ProblemsOcciput Posterior - the baby's head faces the front of the mother's pelvis instead of turning toward the mother's back. The baby would then be delivered with the head facing the ceiling, which is often a more difficult way to deliver. A large episiotomy may be required.This position occurs more often in women who are having their first baby and women who have a narrow midpelvis.OP- may lead to dysfunctional labour (in primigravida). Contraction may be painful and accompanied by backache
- 11. signs of obstruction/ fetalheart rate is abnormal (less than100 or more than 180 beats perminute) at any stageIf no sign of obstructionCervix is not fully dilated If cervix is fully dilatedcaesarean section.BUT no descent in expulsive phaseAugmented labour with oxytocinIf fetal head is palpable per abdomen3/5 – 1/5 <1/5>3/5Vacuum extraction/ forcepsVacuum extraction/symphysiotomy
- 13. MALPRESENTATIONTypes:Breech 3 in 100Face 1 in 500Brow 1 in 2000Shoulder 1 in 300Compound
- 14. Related Factors:The woman has had more than one pregnancy There is more than one fetus in the uterus The uterus has too much or too little amniotic fluid The uterus is not normal in shape or has abnormal growths, such as fibroids Placenta previaThe baby is preterm
- 15. Breech PresentationPerinatal mortality up to 4 times compared to vertex presentation. Breech presentation only becomes significant after 36weeksTypes of Breech Presentation:Complete (Flexed) Breech Presentation Footling Breech PresentationFrank (Extended) Breech PresentationKneeling Breech Presentation
- 16. Predisposing factors:Fetal Prematurity Fetal abnormality Intrauterine deathPlacental Placenta praevia Placental cornualAmniotic fluid PolyhydramniosUterine/ pelvic Bicornuate/ septate Pelvic masses
- 19. BREECH PRESENTATION-- ManagementAfter 36 weeksExternal cephalic versionSpontaneous version
- 20. BREECH PRESENTATION-- External Cephalic VersionAttempt external cephalic version if: Breech presentation is present at or after 36 weeks Vaginal delivery is possible; Membranes are intact and amniotic fluid is adequate; There are no complications (e.g. fetal growth restriction, uterine bleeding, previous caesarean delivery, fetal abnormalities, twin pregnancy, hypertension, fetal death).
- 21. BREECH PRESENTATION-- External Cephalic VersionRisks:Placental abruptionPremature rupture of the membranesCord accidentTransplacental haemorrhageFetal bradycardia
- 22. BREECH PRESENTATION-- External Cephalic VersionAbsolute contraindication:Previous scar on the uterusPlacenta praeviaUnexplained APHPre-eclampsiaMultiple pregnancyRelative contraindications:Rhesus isoimmunisationElderly primigravidaIUGROligo/ polyhydramnios
- 24. Principle: ‘Masterly inactivityThe following points are important for the safe conduct of a breech delivery: • Don’t be in hurry. • Never pull from below and let the mother expel the fetus by her own effort with uterine contractions • Always keep the fetus with its back anterior • Keep a pair of obstetrics forceps ready should it become necessary to assist the aftercoming head • Anesthetist and pediatrician should attend the delivery • Inform the operation theater, if C/S is needed.
- 25. BREECH PRESENTATION-- Vaginal Breech DeliveryAwait for spontaneous labourA vaginal examination is done not only to assess the progress of labour If the membranes rupture, do a vaginal examination immediately to exclude uterine cord prolapse. If the membranes not rupture, examine for cord presentation.Do not rupture the membranesExamine and monitor the woman regularly and adhere strictly to the partogram.Poor progress may occur if sacrum is posterior/ bigger baby than expectedIf there is any delay, the fetus is best delivered by an emergency caesarean section.
- 26. BREECH PRESENTATION-- Vaginal Breech DeliveryDelivery of the buttocksOccur naturallyDelivery of the legs and lower bodyLegs flexed : spontaneous deliveryLegs extended : ‘Pinard’s manoeuvre’Delivery of the shouldersLoveset’s manoeuvreDelivery of the headBurns Marshall methodMariceau-Smellie-Veit manoeuvreForceps delicery of the aftercoming head
- 27. Pinard’s manoeuvreIn breech with extended legs once the groin is visible gentle pressure can be applied to abduct the thigh and reach the knee. The knee can be flexed with pressure in the poplitealfossa and the leg delivered. Anterior leg is always delivered first.
- 28. BREECH PRESENTATION-- Vaginal Breech DeliveryLoveset’smanoeuvreThis procedure automatically corrects any upward displacement of arms.
- 29. In Lovset’s maneuver baby’s trunk is made to rotate with downward traction holding the baby at the iliac crest so that posterior shoulder comes below symphysis pubis and the arm is delivered by flexing the shoulder followed by hooking at the elbow and flexing it followed by bringing down the forearm ‘like a hand shake’.
- 30. The same procedure is repeated by reverse rotation of 180 degree so that anterior shoulder comes below the symphysis pubis. Burns Marshall methodFor delivery of the aftercomingheadIt is commonly practice where the baby is allowed to hang for a minute or so, The assistant gives a suprapubic downward and pressure (Kristellar’s maneuver) to promote the head. Once the nape of the neck is visible, identified by the hairline, the baby’s trunk is gently lifted and swung toward mother’s abdomen holding the baby just above the ankle through an arc of 180 degree.Left hand guards and slips the perineum over fetal mouth. As the mouth is born air passage is cleared of mucus and now depressing the trunk the head is allowed to born.
- 32. Mariceau-Smellie-Veit ManoeuvreJaw flexion and shoulder traction—JFST(Mariceau-Smellie-VeitManoeuvre)Here the baby is allowed to rest on the left supinated forearm of the obstetrition, with the limbs hanging on either side.
- 33. Left index and middle finger is placed on the malar bones, while the right index and ring fingers are placed on the respective shoulders and the middle finger on the sub-occipital region.
- 34. To achieve flexion, traction is now given in downward and backward direction and simultaneous suprapubic pressure is maintained by the assitant until the nape of the neck is visible.
- 35. Thereafter, the baby is pulled in upward and forward direction so that the face is born and by depressing the trunk the head is born. Forceps delicery of the aftercomingheadThe long Das/Simpson’s obstetric forceps can be used instead of Piper’s forceps. The important prerequisite is that head must be in the pelvic cavity and the occiput is directly anterior, i.e. the face is facing the posterior pelvic wall.Baby is lifted up by the assistant without deviating the trunk to any side and forceps is applied from ventral side.
- 36. BREECH PRESENTATION-- ManagementAfter 36 weeksExternal cephalic versionSpontaneous versionhas not occuredunsuccessfulFollow-ups antenatally until 38 weeksCaesarean sectionVaginal breech delivery
- 37. BREECH PRESENTATION-- Caesarean SectionFactors that favour:EBW > 3.5 KgSmall pelvis (anterior posterior inlet or outlet diameter of less than 11cm )Preterm fetusFootling/ flexed breechHyperextended headPatient with poor obstetric historycomplications in the present pregnancy such as pre-eclampsia, intrauterine growth restriction, diabetes, cardiac disease, previous caesarean section
- 38. BREECH PRESENTATION-- Caesarean SectionHowever in 2000 the result of the Canadian Term Breech Trial were published. It came out overwhelmingly with the conclusion that singleton breech presentations at term should preferably be delivered by caesarean section. Not to do so would invite unacceptable fetal morbidity or mortality. There is therefore now a trend to deliver all breeches at term by caesarean section.
- 39. be remembered however, the results of the study do not apply to twin pregnancy with breech presentations, preterm breech deliveries breech presentations that arrive late in advanced labour. In those situations there still appears to be a role for delivering the baby vaginally.
- 40. Face Presentation- head is hyper extended- presenting part is face- denominator is chin (mentum)- between glabella & chin - presenting diameter is submentobregmatic (9.5cm) AETIOLOGY
- 41. FACE PRESENTATION-- DiagnosisIs caused by hyperextension of the fetal head so that neither the occiput nor the sinciput are palpable on vaginal examination.On abdominal examination, a groove may be felt between the occiput and the back.On vaginal examination, the face is palpated, the examiner’s finger enters the mouth easily and the bony jaws are felt.
- 42. FACE PRESENTATION-- DiagnosisThe chin serves as the reference point in describing the position of the head.It is necessary to distinguish only chin-anterior positions in which the chin is anterior in relation to the maternal pelvis from chin-posterior positions.
- 43. FACE PRESENTATION-- ManagementProlonged labour is common.Descent and delivery of the head by flexion may occur in the chin-anterior position.In the chin-posterior position, however, the fully extended head is blocked by the sacrum. This prevents descent and labour is arrested-> caesarean section
- 44. FACE PRESENTATION-- Management of Chin-anteriorCervix fully dilatedCervix not fully dilatedAllow normal child birthAugmentation of labourSlow progress with no signs of obstructionDescent unsatisfactoryAugmentation of labourForceps delivery
- 45. Brow PresentationThe brow presentation is caused by partial extension of the fetal head so that the occiput is higher than the sinciput.MGT: If the fetus is alive or dead, deliver by caesarean section. *Do NOT deliver brow presentation by vacuum extraction, outlet forceps or symphysiotomy.Mentovertical D = 14cmAttitude = Partial Extension
- 46. Shoulder PresentationOccurs as a result of transverse lie or oblique liePredisposing factors = breech presentationOn abdominal examination, neither the head nor thebuttocks can be felt at the symphysis pubis and the headis usually felt in the flank. On vaginal examination, a shoulder may be felt, but not always. An arm may prolapse and the elbow, arm or hand may be felt in the vagina.Ultrasound examination
- 47. ManagementMonitor for signs of cord prolapse. If the cord prolapses and delivery is not imminent, deliver by caesarean section.In modern practice, persistent transverse lie in labour is delivered by caesarean section whether the fetus is alive or dead.
- 48. Compound PresentationOccurs when an arm prolapses alongside the presenting part. Both the prolapsed arm and the fetal head present in the pelvis simultaneously.
- 49. ManagementReplacement of the prolapsed arm Assist the woman to assume the knee-chest position Push the arm above the pelvic brim and hold it there until a contraction pushes the head into the pelvis. Proceed with management for normal childbirthIf the procedure fails or if the cord prolapses, deliver by caesarean section
- 50. SUMMARY
- 51. THANK YOU
Editor's Notes
- #7: It is usually seen in multipara or those with lax abdominal wall. Fetal malpositions are assessed during labor.
- #16: *The perinatal mortality can be up to 4 times that of vertex presentation. Reasons: Higher incidence of fetal abnormalityHigher incidence of cord prolapseDifficulty in delivering the shouldersDifficulty in delivering the head.In inexperienced hands