Book Reading

MALPRESENTATION
Presented By :
Dr. Nico Poundra Mulia
Moderator :
Dr. Fatmah Oktaviani, SpOG

KEYPOINTS
Malpresentation
associated with uterine anomalies,
fibroids, placenta previa, grand multiparity, pelvic tumors,
prematurity, multiple gestation, polyhydramnios, short
umbilical cord, fetal anomalies, prior breech delivery.
Complications of breech presentation
congenital
anomalies, preterm birth (PTB), birth trauma, low Apgar
scores, cord prolapse

DEFINITIONS
Presentation
Fetal body part that is in
the lower uterine segment (lowest in the uterus
and closest to the cervix).
Malpresentation
the fetal head
segment.

Fetus presenting with

not in the lower uterine

MALPRESENTATION
Symptoms
Maternal impression of fetal presentation based on fetal movementis
suggestive but overall unreliable for predicting fetal Presentation
Epidemiology/Incidence
Breech presentation complicates 3% to 4% of all pregnancies at term (37
weeks).

CLASSIFICATIONS
Breech
Fetus presents in longitudinal lie with head not in the lower uterine
segment.
Fetal breech presentation is further classified as follows:
CompleteFlexion of the fetal hips and knees
IncompleteExtension of one or both hips (includes footling)
FrankFlexion at the hips and extension at the knees

CLASSIFICATIONS
Transverse
The fetal longitudinal axis is perpendicular to the long axis of the uterus. The fetus can
either present back up (fetal small parts present to the cervix), or back down (fetal
spine or shoulder present to the cervix).
Oblique
The fetal longitudinal axis is diagonal to the long axis of the uterus.
Face
The fetal head is hyperextended so that the fetal occiput is in contact with the fetal back
and the mentum (chin) is presenting.

CLASSIFICATIONS
Brow
The presenting part is the portion of the fetal head between the orbital ridge
and the anterior fontanel.

 Compound
Simultaneous presentation
of
a
prolapsing
fetal
extremity
and
the
presenting part.

RISK FACTORS/ASSOCIATIONS
Uterine anomalies, fibroids, placenta previa, grand multiparity, contracted
maternal pelvis, pelvic tumors, prematurity, multiple gestation,
polyhydramnios, short umbilical cord, fetal anomalies, and prior breech
delivery.
Prior breech delivery gives a 9% risk of recurrence in subsequent
pregnancies.

COMPLICATIONS
Incidence of congenital anomalies (up to 6%), PTB, birth trauma, low
Apgar scores, and lower pH are higher with a breech presentation
compared with a vertex presentation
Breech presentation
a sign and a consequence of fetal compromise,
again regardless of delivery mode.

WORKUP
Fetal presentation should be assessed by Leopolds maneuvers at
each visit starting at 34 weeks of gestation.
If the clinician is unsure, a vaginal examination, or even better, if
still unclear, an ultrasound is indicated to assess fetal presentation.

EXTERNAL CEPHALIC VERSION

Procedure performed by application of pressure and maneuvers to the
maternal abdomen with the goal to turn the fetus to a cephalic
presentation
Complications
short-term fetal bradycardia is as high as 20% or
more, the rate of need for urgent CD for NRFHT after an ECV is about
1/600.
Placental abruption (<1%)

 Contraindications
Any contraindications to vaginal delivery such as placenta previa or prior
classical uterine incision

Efficacy
ECV at term is associated with reduction in noncephalic birth and decrease in
CD.

Timing of version
Compared with no ECV attempt, ECV before term reduces noncephalic births.

 Tocolysis.
betamimetics prior to attempt at ECV is associated with 26% fewer failures of
ECV.
Terbutaline 5 mg subcutaneously once, 10 to 15 minutes before ECV,
Intravenous salbutamol tocolysis prior to ECV increased success rates,
decreased CD rate, and was well tolerated.

Tocolysis can be used with success also in a second ECV attempt after a
first ECV attempt has failed

 Nitroglycerin
Nifedipine

improve version success rates.

did not significantly improve the success of ECV

 Fetal acoustic stimulation to the fetal head for 1 to 3 seconds in midline

fetal spine positions
fewer failures of ECV at term
The success rate in the control group of this study was much lower than
expected (8%).
The evidence is insufficient to make a recommendation.

 Anesthesia
There is limited convincing evidence that regional anesthesia affects ECV
success.
ECV failure, noncephalic births, and cesarean sections were reduced in two
trials with epidural

ECV success rates increased from 33% to 59% with epidural in one study
and from 32% to 69% in another.

 ECV procedure
Given the possible complications, it is prudent to
perform ECV in a facility with ready availability for emergency CD.
Consent should
complications.

be

obtained

after

counseling

regarding

possible

A nonstress test should be performed before and after the procedure.

Betamimetic prophylactic tocolysis should be given (e.g., terbutaline 5
mg subcutaneously 5 to 10 minutes prior to procedure).

MOXIBUSTION AND/OR
ACUPUNCTURE
Moxibustion is a form of traditional Chinese
medicine that uses heat generated by
burning herbs
There is inconsistent evidence to assess if
the use of moxibustion significantly converts
a breech to a cephalic presentation.
A more recent small RCT
reported no
beneficial effect of moxibustion to facilitate
ECV with the percentage of versions similar
between moxibustion (18%) and controls
(16%).

MATERNAL CHANGE IN POSTURE

Maternal change in position such as knee-chest
suggested as a
means to correct breech presentation in pregnancy.
There is insufficient evidence from the small trials reported so far to
support the use of postural management for breech presentation.
Meta-analysis of these data could not be done as study designs and
outcomes measured were different.

DELIVERY OUTCOMES
The rate of CD after ECV is still about double that of pregnancies
presenting with spontaneous cephalic presentation because of
higher incidences of dystocia and NRFHT after successful ECV.

MODE OF DELIVERY
Singleton Term
Term breech. Three RCTs (39), including one large study , have
compared a policy of planned CD to a policy of planned trial of labor
to attempt a vaginal delivery.
CD occurs in about 45% of those women allocated to a vaginal
delivery protocol and >90% in those allocated to a CD protocol.
At three months after delivery, women allocated to the planned
cesarean section group reported 38% less urinary incontinence;
89% more abdominal pain; and 68% less perineal pain.

Technical aspects.
Cesarean breech delivery: There are no trials to assess technical aspects
of breech (or other malpresentation) CD.
There is insufficient evidence to assess if intra-abdominal version during
CD before uterine incision affects outcomes.
Vaginal breech delivery
vaginal breech delivery.

several technical suggestions for assisting a

PRETERM
The premature breech
There is insufficient evidence to assess if outcomes of the preterm fetus
presenting breech are affected by mode of delivery.
Very little prospective data, mostly nonrandomized, exists regarding
vaginal versus CD of the premature breech infant.

TWINS
Pregnancies at 35 to 43 weeks with vertex/breech presentation in twin
gestations <7 cm dilated have similar Apgar scores or incidence of
neonatal morbidity in the second twin if delivered by vaginal or cesarean
birth in a very small trial.
No incidence of birth trauma or IVH in any of the 27 breech deliveries.
Maternal febrile morbidity and length of stay was increased in the
cesarean group

THANK YOU