Malpresentation & Malposition

Question 1

Abnormal lie

Answer 1

 Abnormal lie is where the long axis of the fetus is not lying along the
long axis of the mother’ s uterus ie,
a) TRANSVERSE
b) OBLIQUE
c) UNSTABLE
NB: LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH) is NORMAL

Question 2

Malposition

Answer 2

Malposition refers to any position of the vertex other than flexed occipito-anterior one
 Where the fetus is lying longitudinally & vertex is presenting, but it is not in Occipito Anterior (OA) position.\

Question 2

OccipitoTransverse

Answer 2

1) OccipitoTransverse (OT) - fetal occiput is either to maternal left or right
 Occipito-transverse- is the incomplete rotation of OP to OA
 Results in the fetal head being in a horizontal or transverse position (OT)

Question 2

OccipitoPosterior (OP)

Answer 2

2) OccipitoPosterior (OP)- vertex presentation where the occiput is placed posteriorly
over the sacroiliac joint or directly over the sacrum
 It’s an abnormal position of the vertex rather than an abnormal presentation and with anterior rotation as in
majority of cases, follows the course like of an occipito-anterior
 Posterior position occasionally gives rise to dystocia,
a) Right occipito-posterior (ROP)- occiput is placed over right sacroiliac joint, aka 3rd position of vertex
b) Left occipito-posterior (LOP)- when occiput is placed over lf sacroiliac joint aka 4th position of vertex
 Occiput Posterior-Arrested labor may occur when the head does not rotate and/or descend
 Delivery may be complicated by perineal tears or extension of an episiotomy
 It is a favorable position in anthropoid pelvis

Question 3

Normal occipital positions

Answer 3

a) Right occipital anteriorb) Left occipital anteriorc) Occiput anterior

Question 4

Factors that favour malposition

Answer 4

a) Pendulous abdomen- in multiparae
b) Anthropoid pelvic brim- favours direct O.P over O.A
c) Android pelvic brim
d) A flat sacrum-transverse position
e) Attachment of Placenta on the ant. uterine wall - favors a well flexed fetus ovoid looking towards the anterior
wall of the uterus, i.e. remains in dorso-posterior position
f) Abnormal uterine contraction may cause or, lead to persistent deflexion and occipito-posterior position

Question 5

How to diagnose malposition

Answer 5

 Course of labour usually normal, except for prolonged 2nd stage (>2hours)
 Abdominal examination :
a) Lower part of the abdomen is flattened
b) Difficult to palpate fetal back.
c) Fetal limbs are palpable anteriorly
d) Fetal heart may be heard in the flanks
 Vaginal examination:
a) Posterior fontanelle towards the sacral-iliac joint (difficult)
b) Anterior fontanelle is easily felt, if head is deflexed
c) Fetal head may be markedly molded with extensive caput, making diagnosing correct station and position hard

Question 6

Management of malposition

Answer 6

 Spontaneous rotation to occiput anterior occur in 90% of cases Esp. in good uterine contraction, spacious pelvis,
average size fetus
 If arrest of labour occurs in 2nd stage of labour proceed as follows:
1. Emergency Cesarean section
2. Ventouse delivery

Question 7

Malpresentation

Answer 7

Definition- where the fetus is lying longitudinally, but presents in any manner other than vertex

Question 8

types of Malpresentation

Answer 8

Breech presentation is the most commonly encountered malpresentation and occurs in 3–4% of term pregnancies,
1) BREECH- lie is longitudinal and the podalic pole presents at the pelvic brim.
2) FACE- occurs when the fetal head is hyperextended such that the fetal face, between the chin and orbit, is the
presenting part.
3) BROW- occurs when presenting part of the fetus is between
the facial orbits and anterior fontanelle
 Arises as the result of extension of the fetal head such that
it is midway between flexion (vertex presentation) and
hyperextension (face presentation)
 Supraorbital ridges and the bridge of the nose are palpable
4) SHOULDER
5) COMPOUND

Question 9

Malpresentation incidence

Answer 9

 Breech 3 in 100
 Face 1 in 500
 Brow 1 in 2000
 Shoulder 1 in 300
 Compound

Question 10

Complications of breech presentation

Answer 10

1. Increased risk of prolapsed cord.
2. Increased risk of CTG abnormalities.
3. Mechanical difficulties with delivery of shoulders/head

Question 11

Types of Breech Presentation

Answer 11

 There are 2 varieties; Complete and Incomplete
1. Complete (Flexed breech): normal attitude of full flexion is maintained with thighs flexed at the hips and the
legs at the knees
 Presenting part consists of 2 buttocks, external genitalia and 2 feet
 The baby’s hips and knees are flexed so that the baby is sitting cross legged, with feet beside the bottom
2. Incomplete breech: Has varying degrees of extension of thighs or legs at the podalic pole.
 Three varieties are possible:
a) Frank (Extended) Breech Presentation - thighs are flexed on the trunk &
legs are extended at the knee
* The baby’s bottom comes first, and the legs are flexed at the hip and
extended at the knees (with feet near the ears).
* 65-70% of breech babies are in the frank breech position
b) Footling Breech Presentation- Both thighs and legs are partially
extended, presenting the legs at the brim
c) Knee presentation: Thighs are extended but knees are flexed, bringing the
knees down to present at the brim

Question 12

Etiology of breech presentation

Answer 12

Maternal causes
1) Multiparae with lax abdominal wall.
2) Polyhydramnios
3) Oligohydramnios
4) Uterine abnormalies (bicornuate, uterus)
5) Pelvic tumour
6) Uterine surgery
7) Contracted pelvis
Fetal causes
1) Prematurity
2) Multiple pregnancy
3) Fetal anomalies (hydrocephalus,
anencephaly, Trisomies [13, 18, 21], and myotonic dystrophy due to altered fetal muscular tone and mobility)
4) Short cord, relative or absolute,
5) Intrauterine death of the fetus
Placental causes
1) Placenta previa,
2) Cornufundal attachment of the placenta

Question 13

Diagnosis of breech presentation

Answer 13

Diagnosed through; Clinical * Sonography
Clinically
a) Leopold maneuvers,
b) Pelvic examination
Sonography
c) Ultrasound- confirms clinical diagnosis, detect fetal congenital abnormality and also uterine congenital
anomalies, type of breech, liquor vol (important for ECV) & fetal head attitude (flexion or hyperextension

Question 14

Management of breech

Answer 14

 At or after 36 weeks
 Confirmation by ultrasound
 External Cephalic Version (ECV)
 Elective Caesarean Section

Question 15

External Cephalic Version

Answer 15

 Procedure by which obstetrician manually converts the breech
fetus to a vertex presentation via external uterine manipulation
under ultrasonic guidance.
 Attempt external cephalic version if:
 Breech presentation is present at or after 37 wks
 Performed with tocolytic agents, (e.g. Nifedipine)
 Should last not more than 10 minutes
 Perform Fetal heart rate tracing before & after procedure

Question 16

Criteria for ECV

Answer 16

a) Normal fetus,
b) Adequate fluid,
c) Reassuring fetal heart tracing,
d) Unengaged presenting part,
e) And no previous uterine surgeries

Question 17

Contraindication for External Cephalic Version

Answer 17

a) Fetal abnormality
b) Antepartum hemorrhage (placenta previa or abruption) - risk of placental separation
c) Ruptured membranes or - Oligo- or poly- hydramnios
d) Known congenital malformation of the uterus
e) Abnormal cardiotocography- nonreassuring fetal monitoring
f) Contracted pelvis
g) Previous uterine surgery
h) Evidence of uteroplacental insufficiency
i) Intrauterine growth restriction
j) Obstetric complications: Severe pre-eclampsia, obesity, elderly primigravida, bad obstetric history (BOH)
k) Rhesus isoimmunization Hypertension
l) Multiple gestation

Question 18

Causes of failure of externa cephalic version

Answer 18

a) Breech with extended legs- early engagement of presenting part and difficult to flex the trunk because of
splinting action of the limbs.
b) Scanty liquor
c) Big size baby.
d) Mechanical- obesity, increased tone of abdominal muscles and irritable uterus.
e) Short cord- either relative (common) or absolute.
f) Uterine malformations- septate or bicornuate.

Question 19

Risks of External Cephalic version

Answer 19

a) Placental abruption
b) Premature rupture of the membranes
c) premature onset of labor
d) Amniotic fluid embolism
e) Cord accident
f) Transplacental haemorrhage (remember anti D administration in Rhesus-negative women)
g) Fetal bradycardia

Question 20

Pre requisites for Vaginal breech delivery

Answer 20

1) Frank / complete breech
2) > 37 weeks GA
3) No evidence fetopelvic disproportion (Multiparous)
4) No evidence of fetal anormalies
5) Estimated fetal weight: 2.5 kg-3.5Kg
6) Documented flexion of fetal head by ultrasound,
7) Adequate amniotic fluid,
8) Experienced obstetrician in breech delivery and availability of
anesthesia and neonatal team

Question 21

Principle of breech (Handsoff) Vaginal Delivery

Answer 21

 The following points are important for the safe conduct of a breech
delivery
 Never pull from below but 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 after coming head
 Anesthetist and pediatrician should attend the delivery

Question 22

Assisted Vaginal Breech Delivery

Answer 22

 Delivery of the buttocks occur naturally
 Delivery of the legs and lower body
 Legs flexed spontaneous delivery
 Legs extended ‘ Pinard’ s manoeuvre’
 Delivery of the shoulders
 Loveset’ s manoeuvre
 Delivery of the head
 Mariceau-Smellie-Veit manoeuvre
 Forceps delivery of the after coming head

Question 23

Pinard’s manoeuvre

Answer 23

 Used in 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 popliteal fossa and the leg delivered  Anterior leg is always delivered first

Question 24

Loveset’s manoeuvre-Shoulders delivery

Answer 24

 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’  The same procedure is repeated by reverse rotation of 180 degree so that anterior shoulder comes below the symphysis pubis.

Question 25

Mariceau-Smellie-Veit Manoeuvre- head

Answer 25

 Jaw flexion and shoulder traction—JFST (Mauriceau-Smellie-Veit Manoeuvre)  Here baby is allowed to rest on the left supinated forearm of the obstetrician, with the limbs hanging on either side.  Left index and ring fingers are placed on the malar bones, while the right index and ring fingers are placed on the respective shoulders and the middle finger on the suboccipital region.  To achieve flexion, traction is now given in downward and backward direction and simultaneous suprapubic pressure is maintained by the assistant until the nape of the neck is visible.  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

Question 26

Burns-Marshall

Answer 26

 Baby is allowed to hang by its own weight  Assistant gives suprapubic pressure in a downward and back ward direction  Aim is to promote flexion of the head to smallest diameter presenting  When nape of the neck is visible under pubic arch, grasp baby by ankles  Swing the trunk in an upward and forward direction  Suck any mucus and as the mouth clears off perineum

Question 27

Aetiology of face presentation

Answer 27

Maternal a) Multiparity b) Lateral obliquity of fetus c) Contracted pelvis / CPD d) Flat pelvis e) Pelvic tumors Fetal a) Congenital Malformation (anencephaly, Dolichocephalic head, Congenital branchocele) b) Several coils of umbilical cord around the neck c) Musculoskeletal abnormality (spasm/ shortening of extensor muscle of neck) d) Tumors around neck (congenital goiter)

Question 28

Diagnosis of face presentation

Answer 28

 Is 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.  Palpating mouth with hard alveolar margins, nose, malar eminences, supraorbital ridges and the mentum

Question 29

Face positions

Answer 29

 Has 4 positions based on the relation of the chin to the Lf and RT sacroiliac joints or to RT and lf iliopubic eminences.  Numbering of the face positions is obtained as follows:  1 st vertex (LOA) becomes 1 st Face → Right mentoposterior (RMP)  2 nd vertex (ROA) becomes 2 nd Face → Left mentoposterior (LMP)  3 rd vertex (ROP) becomes 3 rd Face → Left mentoanterior (LMA)  4 th vertex (LOP) becomes 4 th Face → Right mentoanterior (RMA)  Left mento-anterior (LMA) is commonest position

Question 30

Management of face positions

Answer 30

 Do overall assessment and note;  Pelvic adequacy (clinical),  Size of the baby,  Associated complicating factors, e.g., elderly primigravidae, SPE, postcesarean pregnancy and postmaturity  Congenital fetal malformation and  Position of the mentum  Prolonged 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 impossible and so do Caesarean section

Question 31

Brow Presentation

Answer 31

 Is caused by partial extension of the fetal head so that the occiput is higher than the sinciput.  Rarest variety of cephalic presentation where the presenting part is the brow  Head lies in between full flexion and full extension  Position is commonly unstable and converts to either vertex or face presentation  Causes are similar to those of face presentations, although some arise as a result of exagerated extension OP.

Question 32

Dx of brow presentation

Answer 32

 Diagnosed in labour by vaginal examination:palpating anterior frontanele, supraorbital ridge and nose  If anterior fontanelle is on the left, with sagittal suture in transverse pelvic diameter, it is left frontum transverse position.  In late labor, the landmarks may be obscured by caput formation

Question 33

Management of brow presentation

Answer 33

 Delivery can be achieved only by caesarean section  Mentovertical D = 13.5cm

Question 34

Shoulder Presentation

Answer 34

 Long axis of the fetus lies perpendicularly to maternal spine or centralized uterine axis, it is called transverse lie.  Or placed oblique to the maternal spine and is then called oblique lie.  Occurs as a result of transverse lie or oblique lie and as such both are collectively called shoulder presentations  Back is the denominator  Position is determined by direction of the back a) Dorsoanterior-commonest. b) Dorsoposterior c) Dorsosuperior d) Dorso-inferior last 2 are rare  Fetal position is termed Rt or Lf according to the position of the head, and Lf ones are more common

Question 35

Predisposing factors of shoulder presentation

Answer 35

a) Placenta previa, b) High parity, c) Prematurity d) Multiple gestation e.g., twins e) Contracted pelvis f) Pelvic tumour, g) Uterine anomaly h) intrauterine death

Question 36

Diagnosis of shoulder presentation

Answer 36

 On abdominal examination,  Neither the head nor the buttocks can be felt at the symphysis pubis and the head is usually felt in the flank.  Pelvic grip- during pregnancy lower pole of the uterus is empty  Uterus is broader and often asymmetrical, not maintaining pyriform shape  Fundal height is less than the period of amenorrhea.  On vaginal examination, a shoulder may be felt, but not always  During labor- Elongated bag of the membranes if not ruptured  Identify shoulder by palpating; acromion process, scapula, clavicle and axilla  Occasionally, prolapsed arm. * Determine position by; supinating thumb of prolapsed hand, it points towards the head, and the palm corresponds to the ventral aspect. * Palpating angle of the scapula, indicates position of the back * Determined by side to which the prolapsed arm shaking hands with the fetus  Delay in diagnosis a risk for cord prolapse and uterine rupture.  Delivery should be by Caesearean Section

Question 37

Compound presentation

Answer 37

 Occurs when an arm prolapses along side the presenting part.  Both the prolapsed arm and the fetal head present in the pelvis simultaneously.  MGNT- Push back hand, if obstruction –CS