‫بسم هللا الرحمن الرحيم‬

 
Malpresentation and Malposition

Supervision by : DR Ashjan Tarayra

Directed by : DR Montaser Asafrah
Summary:
 Definitions
 Risks on mother and fetus
 Predisposing factors
 Breech. occipito posterior. face. brow.
shoulder, compound, cord
Definitions:
1- Presentation:- Portion of the fetus overlying the pelvic inlet . The
most common presentation is cephalic . This is 96% of fetuses at
term.
2- Malpresentation : any presentation others than vertex as (face ,
brow , breech , shoulder , cord and complex presentation ) .
• Occiput: with a flexed head (cephalic presentation)
• Sacrum: with a breech presentation
• Mentum (chin): with an extended head (face presentation)

3- Position : Relationship of a definite presenting fetal part to the

maternal bony pelvis. It is expressed in terms stating whether the
orientation part is anterior or posterior, left or right. The most
common position at delivery is occiput anterior.
4- malposition :- occipito – posterior
position .
5- Denominator: is a bony landmark on the
presenting part used to denote the
position.
- Vertex - occiput
- Face - mentum
 Breech - sacrum
 Shoulder - scapula
Risks on mother and fetus:
1- Prolonged and obstructed labour
2- Ruptured uterus
3- Difficult C/S, forceps, vacuum – traumatic
delivery
4- Complications of puerperium
5- Vesico vaginal fistula
6- Increased maternal and perinatal
mortality
Prevention of Risks:
1- Early diagnosis .
2- Monitoring .
3- Trained attendant .
Predisposing factors (in most cases no factor):
1-Pre-maturity
2-Contracted pelvis- malformation
3- Multiple pregnancy
4- Polyhydramnios
5- Big baby
6- Congenital malformation of fetus
7- Congenital malformation of uterus
8- Fibroids
9- Placenta Previa
10 Oligohydramnios
11- Pendulous abdomen, grand multipara
:BREECH PRESENTATION
Incidence 3-4% at term -1
Denominator sacrum -2
Diagnosis -3
Head occupies the fundus (hard, rounded,
ballotable , tender)
Breech above pelvic brim (broad, soft,
irregular)
Longitudinal lie
Fetal heart above umbilicus
U/S: confirm diagnosis .Diagnose , maturity,
placenta previa , fibroids, fetal malformation,
twins, uterine malformation, liquor.
Vaginal examination reveal :- 3 bony landmarks
2ischial tuberosities , 1 tip of sacrum in frank ,
feet in footling , male genital baby , fresh
meconium .
4- Types of breech:
A- Incomplete, frank, extended- 60-70%. Thighs
.flexed at hip, extended at knee
 Easy engagement, prevent cord prolapse
B- Complete : Flexion at hip and knee irregular,
affect engagement
C- Footling : One foot presents
D- Kneeling : knee presents
5- Risks to mother:
 Dystocia, sepsis, lacerations, C/S

6- Risks to the fetus:

-: Stillbirth due too 6.1
Intracranial hemorrhage Rapid molding and rapid -
correction of moldings Rapid uncontrolled delivery
Asphyxia Slow delivery. Pressure of cord -
between fetal body and pelvic wall
.Spinal cord injury -
Other injuries ( brachial plexus - femur- liver) 6.2
Intrapartum asphyxia (dystocia, cord prolapse) 6.3
Management Antepartum:
1- Identify cause by U/S
2- External Cephalic Version (ECV)
3- If ECV fail: Decide C/S or assisted
vaginal delivery
 ECV:
In hospital where C/S can be done
immediately
37 weeks. <37 = per-term. > 37 = difficult
Success= 60% in multipara
in primigravida 40%
Preparation (ECV):
U/S: confirm, back , IUGR, liquor
CTG: 20 min before Procedure . well
Nothing by mouth
Empty bladder
I.V line
0.25 mg terbutaline subcutaneous 15 min
before start ( tocolytics )
Trendelenburg position
Procedure (ECV):
Elevate breech from pelvis
Flex fetus and rotate in direction of nose
Transverse
Guide head in pelvis
CTG for 30 min (reactive- no contraction)
-: Stop Procedure (ECV)
If no success after 15 min .
Stop if severe pain or bradycardia .
If bradycardia persists revert
ECV .
If still bradycardia do C/S .
Contraindications for ECV:
 Vaginal delivery not possible ( contracted pelvis )
 Multiple pregnancy
 IUGR or hydrocephalus
 Previous C/S
 APHg
 Pre-eclampsia
 Ruptured membranes
 Cardiac disease
 Uterine abnormality
 Rhesus negative
Complications of ECV:
 Cord accident.
 Premature labour .
 Accidental hemorrhage (separation placenta).
 IUFD.
 Feto - maternal transfusion .
 Foetal distress .
May Difficult ECV due to :
Primigravida .
Obese mother .
Decrease liquor .
Anterior placenta .
Early labour .
Big baby .
Irritable uterus .
If ECV fails decide:
Vainal delivery , C/S
Indication of Elective C/S in breech presentation :-
Hypertension, diabetes, APH .
Big baby ≥ 3.8 kg .
Contracted pelvis .
IUGR .
Previous SB .
Relative infertility .
Primigravida .
Previous C/S .
Footling .
Hydrocephalus .
Hyperextended head .
Vaginal delivery in breech
presentation : -
-Adequate pelvis .
- Wt: < 3.8 kg and GA 36 – 42 .
- uncomplicated pregnancy .
- Multipara .
- an experienced obstetrician
- Malformed baby or IUFD .
 There is tow method of second stage of
labour in brech presentation .

1. spontaneos breech delivery

2. assisted breech delivery
OCCIPITOPOSTERIOR (OP) :
It is a vertex presentation with foetal back
directed posteriorly .
Incidence 10% at onset of labour .
ROP more common than LOP .
Causes ( unknown , shape of pelvis
“anthropoid , android “, epidural analgesia ,
maternal kyphosis , Ant insertion of placenta
, pp , pendulous abdomen ,
polyhydramnios , Multiple pregnancy ) .
Diagnosis:
Flat abdomen below umbilicus .
Fetal parts anterior.
Difficult to feel the back .
Fetal heart at flanks .
Vaginal Examination:
Early in labour Head is high and anterior
fontanelle occupies the center. Posterior
fontanelle high and sagittal suture
anteroposterior .
Features in labour:
Back pain
Prolonged and Obstructed labour
Early rupture of membranes
Cord prolapse
Lacerations-vagina perineum
Management:
1-Similar to occipito anterior
2- Monitoring
Fetal distress
Maternal distress
Failure of progress
3- In primigravida syntocinon may correct
position .
Management:
4- Mode of delivery:
Spontaneous delivery face to pubis
Fetal distress or maternal distress or cord prolapse in
first stage=CS
Failure of progress (after syntocinon) in first stage=C/S
Fetal distress or maternal distress in second stage and
head not engaged = C/S .
Vacuum: enhance rotation and delivery OA.
Forceps: Deliver face to pubis .
Manual rotation- flex head + rotate .
:FACE PRESENTATION
1- Incidence 1:300
2- Aetiology :-
Hyperextended head +face presenting
Submentobregmatic diameter 9.5 cm
Usually secondary in labour
i- Big baby
ii-Contracted pelvis
iii-Pendulous abdomen of grand multipara
iv-Premature
v- Goitre , anencephaly
3- Diagnosis:
Vaginal examination
Frontal bones, supraorbital ridges, eyes,
nose, mouth, chin.
Mouth(suckling reflex, alveolar margin,
mouth and maxilla form triangle)
Anus: Straight line with ischial tuberosities.
Face presentation (cont):
4- Labour:
Face bones not comperssable
Submento bregmatic diameter 9.5 cm
Prolonged labour, early rupture of membranes
Starts mento-lateral and rotates to mentoanterior
Neck fixed under pubic arch and head delivers
by flexion
Mento posterior rotates to mento anterior
Persistent mento posterior- impossible vaginal .
Face presentation (cont):
5- Management:
Evaluate condition carefully after diagnosis
Vaginal delivery – Mento anterior and mento
lateral: Monitor (F dis ,M dis , Failure
progress)
Large episiotomy .
Face presentation (cont):
6- Management:
Contraindicated
○ Syntocinon.
○ Vacuum
○ Scalp electrode

Forceps may be used -

Face presentation (cont):
5- Management:
Caesarean section
○ Contracted pelvis
○ Big bay
○ Previou C/S
○ Hypertension, APH, diabetes
○ Presistent mento posterior
:Face presentation (cont)
Dead fetus
○ Craniotomy
○ C/S
 
 
:BROW PRESENTATION

 
Incidence 1:600
Aetiology similar to face presentation .
Deflexed head. Mento vertical diameter 13.5 cm
- Diagnosed by vaginal exam
Frontal sutures, anterior fontanelle, supra
orbital ridges, eyes, root of nose (mouth
and chin not felt)
- Management:C/S
TRANSVERSE LIE OR SHOULDER
:PRESENTATION
Incidence 1:300
Aetiology
○ Multiparous
○ Pendulous abdomen
○ Pre-term
○ Placenta previa
○ Abnormal uterus
○ Contracted pelvis
○ Polyhydramios
○ Malformed baby
Transverse lie or shoulder presentation (cont):
Diagnosis:
Asymmetrical abdomen
Fundus less than dates
Head usually to the left
In back down transeverse lie the shoulder is over
the pelvic inlet (shoulder presentation)
In back up transever lie (second twin)
Oblique lie
Unstable lie
Empty pelvis
Transverse lie or shoulder presentation
(cont):
Vaginal examination:
Early labour: bag of water with fetal parts
Late labour: membranes ruptured
Shoulder presents in back down transevers
lie (ribe in medial side of axilla, clavicle,
acromion)
Arm proplapse.
Transverse lie or shoulder presentation (cont):
Features of labour:
Ruptured membranes + cord proplapse
Obstructed labour
ruptured uterus
Neglected shoulder presentation =
(impending rupture uterus )= (distress
mother , sholder is impacted with prolapsed arm
or cord , membrain ruptured scinc a time liquor
is drained , fetus distressed or dead )
Transverse lie or shoulder presentation
(cont):
Management Antepartum:
1- U/S (Placenta Previa etc)
2- Attempt ECV
3- C/S
 Management in labour:
C/S
PROPLAPSE AND PRESENTATION OF
:CORD
Aetiology:
1- Malpresentaion malposition
2- Multiparous-high head at start of labour
3- Polyhydramnios
4- ARM-high head
5- ECV
6- Forceps-vacuum
7- Long cord
8- Pre-term.
Prolapse and presentation of the cord
(cont):
1- Proplapse: Membranes ruptured
 Diagnosed:

visual, vaginal examination , Bradycardia

, Cord spasm , Asphyxia .
2- Presentation: membranes not ruptured
(C/S)
 Management of Prolapsed cord:
1- Keep cord in vgina
2- Elevate foot of bed , fill bladder
3- Never attempt to reposition in uterus
4- Forceps : if alive + fully dilated cervix .
5- C/S : alive + not dilated cervix .
6- Vaginal : if dead fetus .
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