FETAL MALPRESENTATION

and
MA L POS ITION
 MALPRESENTATION & MALPOSITIONS
• Malposition and its management:
OccipitoPosterior
OccipitoTransverse

• Malpresentation and its management:

breech
face
brow
shoulder
compound
Occiput Anterior Positions
 DEFINITION
• Abnormal lie where the long axis of the fetus is not
lying along the long axis of the mother’s uterus

TRANSVERSE
OBLIQUE
UNSTABLE

• LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH)

is NORMAL
 MALPOSITION
• Malposition where the fetus is lying
longitudinally and the vertex is presenting, but
it is not in the OccipitoAnterior (OA) position

OccipitoTransverse (OT)

OccipitoPosterior (OP)
Factors that favour malposition
Pendulous abdomen- in multiparae
Anthropoid pelvic brim- favours direct
O.P/O.A
Android pelvic brim

A flat sacrum-transverse position

The placenta on the ant. uterine wall

Malpositions include occipitoposterior and occipitotransverse positions of fetal
head in relation to maternal pelvis.

Occiput Posterior
Occiput Transverse

Arrested labor may occur when the head does

not rotate and/or descend. Delivery may be It is the incomplete rotation of OP to OA
results in the fetal head being in a horizontal or
complicated by perineal tears or extension of
an episiotomy. transverse position (OT).
 Left Occipitoanterior Rotation

• (A) A fetus in cephalic presentation, LOA position. View is

from outlet. The fetus rotates 90 degrees from this position.
(B) Descent and flexion (C) Internal rotation complete. (D)
Extension; the face and chin are born
Left Occipitoposterior Rotation
• (A) Fetus in cephalic
presentation LOP
position. View is from
outlet. The fetus
rotates 135 degrees
from this position. (B)
Descent and flewion.
(C) In ternal rotation
beginning. Because
of the posterior
position, the head will
rotate in a longer arc
than if it were in an
anterior position. (D)
Internal rotation
complete. (E)
Extension; the face
and the chin are born.
(F) External rotation;
the fetus rotates to
place the shoulder in
an anteroposterior
position
 Maternal risks: Maternal symptoms:
• prolonged labor • Intense back pain in
• potential for operative labor
delivery • Dysfunctional labor
• extension of pattern
episiotomy, • prolonged active phase
• 3rd or 4th degree • secondary arrest of
laceration of the dilatation
perineum. • arrest of descent

D
Abdominal examination - the lower part of the abdomen is
flattened, fetal limbs are palpable anteriorly and the fetal flank.
Vaginal examination - the posterior fontanelle is toward the
sacrum and the anterior fontanelle may be easily felt if the head
is deflexed
Ultrasound
 How to diagnose :
Course of labour usually normal, except for prolonged
second 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 deflexed
c) Fetal head may be markedly molded with extensive caput,
making diagnosing correct station and position difficult. 8
 Nursing MGT
Encourage the mother to lie on her side from the fetal back,
which may help with rotation.
Pelvic - rocking may Knee - chest position
help with rotation. may facilitate rotation.

Apply sacral counter - pressure with heel of hand to relieve

back pain.
Continue support and encouragement:
Keep client and family informed progress.
Praise client’s efforts to maintain control.
 Management
• If there are signs of obstruction or the fetal
heart rate is abnormal at any stage, deliver by
caesarean section.
• If the membranes are intact, rupture the
membranes with an amniotic hook or a
Kocher clamp.
• If the cervix is not fully dilated and there are
no signs of obstruction, augment labor with
oxytocin.
• If the cervix is fully dilated but there is no
descent in the expulsive phase, assess for
signs of obstruction.
 Management
Forceps - provides traction or
a means of rotating the fetal
head.
Risks: fetal ecchymosis or
edema of the face, transient
facial paralysis, maternal
lacerations, or episiotomy
extensions.
Vacuum extraction - Provides
traction to shorten the second
stage of labor.
Risks: newborn
cephalhematoma, retinal
hemorrhage and intracranial
hemorrhage.
 Management
SYMPHYSIOTOMY
A surgical procedure in
which the cartilage of the
symphysis pubis is divided to
widen the pelvis allowing
childbirth when there is a
mechanical problem.
Currently the procedure is
rarely performed in
developed countries, but is
still routine in developing
countries where cesarean
section is not always an
option.
 Nursing Diagnoses:
Impaired gas exchange
Encourage the mother to lie on her side from the fetal back, which may
help with rotation.
Knee - chest position may facilitate rotation.
Pelvic - rocking may help with rotation.
Monitor FHB appropriately
Be prepared for childbirth emergencies such as cesarean section,
forceps-assisted delivery, and neonatal-resuscitation.
Pain
Encourage relaxation with contractions.
Apply sacral counter - pressure with heel of hand to relieve back pain.
Provide comfortable environment.
Teach breathing exercises for use during early labor until client receives
pharmacologic relief.
Monitor physical response for example, palpitations/rapid pulse
 Nursing Diagnoses:

Fatigue
Assess psychological and physical factors that may affect reports of
fatigue level
Monitor physical response for example, palpitations/rapid pulse
Monitor fetal heart beat and contractions continuously.
Refraining from intervening with client during contraction.
Anxiety
Keep client and family informed progress.
Provide support during labor through personal touch and contact.
These methods convey concern.
Continue support and encouragement.
Make the client feel she is somewhat in control of her situation.
Provide client and family teaching.
Identify client’s perception of the threat presented by the situation.
 Malpresentation

Fetal malpresentation refers to fetal

presenting part lying longitudinally but other
than vertex and includes breech, transverse, face,
brow, and sinciput.
Malpresentations may be identified
late in pregnancy or may not be
discovered until the initial assessment
during labor.
 INCIDENCE

Types:

• Breech 3 in 100
• Face 1 in 500
• Brow 1 in 2000
• Shoulder 1 in 300
• Compound
 Breech Presentation
The perinatal mortality can be up to 4 times that of
vertex presentation.Complications are:
- Increased risk of prolapsed cord.
- Increased risk of CTG abnormalities.
- Mechanical difficulties with delivery of shoulders/head

Types of Breech Presentation:

Frank (Extended) Breech Presentation
Complete (Flexed) Breech Presentation
Footling Breech Presentation
 ETIOLOGY

Maternal Fetal Placental

• Polyhydramnios • Prematurity • Placenta previa
• Oligohydramnios • Multiple pregnancy
• Uterine abnormalies • Fetal anomalies
(bicornuate, uterus) (hydrocephalus,
• Pelvic tumour anencephaly
• Uterine surgery
 Frank Breech Complete Breech

The baby's bottom comes The baby's hips and knees

first, and the legs are flexed at are flexed so that the baby is
the hip and extended at the sitting cross legged, with
knees (with feet near the ears).
feet beside the bottom.
65-70% of breech babies are in
the frank breech position.
 Footling Breech Kneeling Breech

One or both feet come first, with The baby is in a kneeling

the bottom at a higher position. position, with one or both legs
This is rare at term but relatively extended at the hips and flexed
common with premature fetuses at the knees. This is extremely
rare.
 BREECH PRESENTATION
Management

At or after 36 weeks

Confirmation by ultrasound

Elective Caesarian Section

Vaginal breech delivery

External Cephalic Version

(ECV)
 Management
If the woman is in early labor and the
membranes are intact, attempt External
Cephalic Version.
Tocolytics, such as Terbutaline 0.25
mg IM, can be used before ECV to help
relax the uterus.
If ECV is successful, proceed with
normal childbirth. If EVC fails or is not
advisable, deliver by caesarean section.
 Management

Attempt external version if:

Breech presentation is present at or after 37
weeks (before 37 weeks, a successful version is
more likely spontaneously revert back to breech
presentation)
- 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, HPN,
fetal death).
 Management

VAGINAL BREECH DELIVERY. A vaginal

breech delivery by a skilled health care
provider is safe and feasible under the
following conditions:
- complete or frank breech
- adequate clinical pelvimetry
- fetus is not too large
- no previous caesarean section for
cephalopelvic disproportion
- flexed head.
 BREECH PRESENTATION
-- Vaginal Breech Delivery
• 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 delicery of the aftercoming head
BREECH MANEUVERS
 Mariceau-Smellie-Veit
Manoeuvre
Jaw flexion and shoulder traction—JFST(Mauriceau-
Smellie-Veit Manoeuvre:
Here the baby is allowed to rest on the left
supinated forearm of the obstetrition, with the
limbs hanging on either side.
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.
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.
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.
Loveset’s
Manoeuvre:
This procedure automatically corrects
any upward displacement of arms.
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.
 Pinard’s manoeuvre
• 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.
 Management

CESAREAN SECTION for breech

presentation. A cesarean section is safer
than vaginal breech delivery and
recommended in cases of:
Double footling breech
Small or malformed pelvis
Very large fetus
Previous cesarean section for cephalopelvic
disproportion
• Hyperextended or deflexed head.
 Transverse Lie

TRANSVERSE
In a transverse lie, a
fetus lies horizizontally in
the pelvis so that the
longest fetal axis is
perpendicular to that of the
mother.
The presenting part is
usually one of the
shoulders (acromion
process), an iliac crest, a
hand, or an elbow.
 Management

• If an infant is preterm and smaller than

usual, an attempt to turn the fetus to a
horizontal lie may be made.
• Most infants in transverse lie must be
born by cesarean birth, however,
because they cannot be turned and
cannot be born normally form this
“wedged” position.
 Face Presentation
- head is hyper extended
- presenting part is face
- denominator is chin (mentum)
- between glabella & chin
- presenting diameter is submentobregmatic (9.5cm)

• AETIOLOGY
Maternal Fetal

• Multiparity • Congenital Malformation

• Lateral obliquity of fetus
• Contracted pelvis / CPD
• Flat pelvis
(anencephaly)
• Several coils of umbilical cord around
the neck
• Musculoskeletal abnormality (spasm/
shortening of extensor muscle of neck)
• Tumors around neck (congenital goiter)
 SINCIPUT
The sinciput presentation
occurs when the larger
diameter of the fetal head is
presented. Labor progress is
slowed with slower descent of
the fetal head.
FACE
The face presentation is caused
by hyper-extension of the fetal
head so that neither the occiput
nor the sinciput is palpable on
vaginal examination.
 Management
In the chin-anterior In the chin-posterior
position prolonged position, however, the
labor is common. fully extended head is
Descent and delivery of blocked by the sacrum.
the head by flexion may This prevents descent
occur. and labor is arrested.
 Cont.,.,
Anterior Position
If the cervix is fully
dilated:
Allow to proceed with
normal childbirth;
If there is slow progress
and no sign of
obstruction, augment
labor with oxytocin;
If descent is
unsatisfactory, deliver by
forceps.
If the cervix is not fully
dilated and there are no
signs of obstruction:
augment labor with
oxytocin.
Chin-Posterior Position
If the cervix is fully
dilated:
Deliver by caesarean
section.
If the cervix is not fully
dilated
Monitor descent, rotation
and progress. If there are
signs of obstruction,
deliver by caesarean
section.
*Do not perform vacuum
extraction for face
presentation.
 Brow presentation

BROW
The brow
presentation is
caused by partial
extension of the
fetal head so that
the occiput is MGT: If the fetus is alive or dead,
higher than the deliver by caesarean section.
sinciput. *Do not deliver brow presentation
by vacuum extraction, outlet
forceps or symphysiotomy.
 Shoulder Presentation
• Occurs as a result of transverse lie
or oblique lie
• Predisposing factors = placenta
previa,high parity,pelvic
tumour,uterine anomaly
• 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.
• On vaginal examination, a
shoulder may be felt, but not
always. Delay in diagnosis risk cod
prolapse and uterine rupture.

• Delivery should be by Caesearean

Section.
 Compound Presentation
• Occurs when an arm
prolapses alongside
the presenting part.
Both the prolapsed
arm and the fetal
head present in the
pelvis
simultaneously.
Management

• Replacement 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
childbirth
• If the procedure fails or if the
cord prolapses, deliver by
caesarean section
 Nursing Care of Clients with
Malpresentations

• Observe closely for abnormal labor patterns.

• Monitor fetal heart beat and contractions
continuously.
• Anticipate forceps-assisted birth.
• Anticipate cesarean birth for incomplete breech or
shoulder presentation.
• Be prepared for childbirth emergencies such as
cesarean section, forceps-assisted delivery, and
neonatal-resuscitation.
• Position pt. in Trendelenburg or knee-chest position.
• Manually raise the presenting part aseptically
 SUMMARY
Presentation Management

Breech Vaginal delivery ± ECV/

Caesarean section
Face Vaginal delivery (chin-anterior)/
Caesarean section (chin-
posterior)
Brow Caesarean section

Shoulder Caesarean section

Compound Replacement of prolapsed arm

Vaginal delivery/ Caesarean
section
THANK YOU