MALPRESENTATION

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MALPRESENTATION

• Dr Sue Walker
• 14.2.00

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LECTURE OVERVIEW

• Abnormal lie, malpresentation and malposition
• Malpresentation and its management
• breech
• face
• brow
• shoulder
• compound

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DEFINITIONS

• Abnormal lie
• where the long axis of the fetus is not lying
  along the long axis of the mother
• LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH)
• TRANSVERSE
• OBLIQUE
• UNSTABLE

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DEFINITIONS

• Malpresentation
• where the fetus is lying longitudinally, but
  presents in any manner other than vertex
• BREECH
• FACE
• BROW
• SHOULDER
• COMPOUND
• CORD

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DEFINITIONS

• Malposition
• where the fetus is lying longitudinally and the
  vertex is presenting, but it is not in the OA
  position
• OT (LOT, ROT)
• OP

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DEFINITIONS

• Malpresentation
• where the fetus is lying longitudinally, but
  presents in any manner other than vertex
• BREECH
• FACE
• BROW
• SHOULDER
• COMPOUND
• CORD

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BREECH PRESENTATION

• Definition
• where the fetal buttocks or lower extremeties
  present into the maternal pelvis
• Incidence
• 15 (30W)
• 3 at term

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AETIOLOGY FLUPP

• Fetal
• prematurity
• multiple
• anomalies often those that restrict the ability
  of the fetus to assume a vertex presentation
• major malformationhydrocephaly, anencephaly,
  meningomyemocoele
• most common malformationcongenital dislocation
  of the hip
• Liquor
• oligohydramnios/polyhydramnios
• Uterine
• anomalies (bicornuate, fibroid)
• Placenta
• praevia
• Pelvis
• contraction, pelvic tumours obstructing birth
  canal

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TYPES OF BREECH

• Frank (breech with extended legs) 65
• both fetal thighs flexed
• both lower limbs extended at the knee
• Complete (fully flexed) 25
• when both fetal thighs and knees are flexed
• Footling (incomplete) 10
• one or both fetal thighs are extended, and one or
  both knees or feet lie below the buttocks

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THE PROBLEM WITH BEING A BREECH..

• FOUR FOLD INCREASE IN PERINATAL MORTALITY DUE
  TO..
• (1) problems associated with the malpresentation
• and
• (2) problems of asphyxia and trauma due to the
  malpresentation

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PROBLEMS ASSOCIATED WITH THE MALPRESENTATION

• (1) prematurity and preterm PROM
• (2) fetal anomalies
• (3) placenta praevia and abruption

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PROBLEMS OF ASPHYXIA AND TRAUMA DUE TO THE
MALPRESENTATION

• (1) cord prolapse
• (2) entrapment of the fetal head
• through partly dilated cervix
• unrecognized disproportion
• (3) traumatic injuries
• CNS, intra-abdominal, nerve palsies, muscle
  injuries
• (4) extension of fetal arms (nuchal arms)

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MANAGEMENT OF BREECH PRESENTATION AT TERM

• Management options
• (1) external cephalic version
• (2) elective caesarean section
• (3) trial of vaginal delivery

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EXTERNAL CEPHALIC VERSION

• CONTRAINDICTAIONS
• 3rd trimester bleeding
• uterine anomalies
• ROM, oligohydramnios
• need for CS for other reasons (placenta praevia,
  contracted pelvis, hyperextended head)
• indicated vaginal delivery (fetal death, anomaly
  best delivered as breech)

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EXTERNAL CEPHALIC VERSION

• SUCCESS
• 60-70
• TECHNIQUE
• after 36W
• CTG prior
• attempt to perform forward somersault
• tocolytic
• CTG after (8 bradycardia 5 fetomaternal
  haemorrhage)
• anti D (if Rh negative)

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ELECTIVE CAESAREAN SECTION

• EFW lt2500g gt3500g
• preterm breech
• hyperextended fetal head
• palcenta praevia
• concerns re. fetal well being, including
  oligohydramnios
• footling breech
• 10 risk of cord prolapse
• ?complete breech
• 5 risk of cord prolapse (c.f. 1 with frank
  breech)
• ?all PG breech

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CRITERIA FOR VAGINAL DELIVERY

• Frank or complete breech
• EFW 2500-3500g
• gestational age gt36 weeks
• fetal head must be flexed
• maternal pelvis must be adequate
• judged clinically or by pelvimetry
• no other maternal or fetal indiaction for CS
• experienced obstetrician, anaesthetist and
  paediatrician present at delivery

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BREECH EXTRACTION

• Where the obstetrician completely removes the
  entire body from the uterus
• ONLY used for operative delivery of the second
  twin (usually in conjunction with an internal
  podalic version) or at caesarean section
• spontaneous or assisted breech delivery is the
  only acceptable method for delivering a singleton
  breech vaginally

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FACE PRESENTATION

• Incidence 0.2
• Mechanics of presentation
• Characterized by extreme extension of the fetal
  head so the face (rather than the skull) presents
  to the birth canal
• Aetiology
• any factor that favours extension such as fetal
  goitre, anencephaly
• high maternal parity
• At diagnosis
• 60 mentoanterior
• 15 mentotransverse
• 25 mentoposterior

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DIAGNOSIS

• Generally diagnosed on vaginal examination in
  labour
• May be confused with breech presentationREMEMBER
• anus has sphincter tone, the mouth does not
• anus is in line with the ischial tuberosities
  mouth forms a traingle with the malar prominences

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MANAGEMENT

• Submentobregmatic diameter equals
  suboccipitobregmatic diameter of vertex
  presentations
• labour occurs by internal rotation with the chin
  delivering under the symphysis, and the head then
  delivers by FLEXION under the symphysis
• 60-80 of face presentations deliver
  spontaneously (approximately 50 of MP
  presentations will undergo rotation during
  labour, and most MT presentations will rotate to
  MA)
• if MP or MT doesnt convert to MA spontaneously,
  caesarean section is indicated
• augmentation for poor progress may be used on a
  face presentation
• forceps may be used on a MA face presentation

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BROW PRESENTATION

• Incidence 11400
• Mechanics of presentation
• head is extended such that attitude is halfway
  between flexion (vertex) and hyperextension
  (face)
• usually transitional- when the head is in the
  process of converting from a vertex to a face or
  vice versa
• presenting part is between the facial orbits and
  anterior fontanelle
• supraoccipitomental diameter is presenting
  13.5cm cf 9.5cm for suboccipitobregmatic
  (vertex) or submentobregmatic (face)

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DIAGNOSIS

• On vaginal examination, palpate
• anterior fonatnelle
• orbital ridges
• eyes

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MANGEMENT IN LABOUR

• Initially expectant
• 50-75 will either flex to a vertex, or extend to
  a face with contractions from behind meeting soft
  tissue and bony resistance below and will
  therefore deliver vaginally
• High incidence of prolonged labour and
  dysfunctional labour
• Persistent brow
• the diameter is undeliverable vaginally
• deliver by caesarean section

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SHOULDER PRESENTATION

• Incidence 0.3
• Mechanics of presentation
• long axis of the fetus is perpendicular to long
  axis of mother (ie occurs in transverse lie)
• mostly the shoulder presents in a transverse lie,
  but alternative presentations are
• hand and arm (may be prolapsed into the vagina)
• cord
• nil (fetal back is down, and above the level of
  the inlet)

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AETIOLOGY

• Fetal
• prematurity, multiple
• Liquor
• polyhydramnios
• Uterine
• anomaly
• Placenta
• praevia
• Pelvis
• contraction, tumour
• Parity
• high maternal parity (80 of cases occur in women
  who are para3 or more)

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DIAGNOSIS

• On abdominal palpation, no fetal pole is
  presenting to the pelvis, and the head is
  palpable in either the right or left iliac fossa
• on vaginal examination, may palpate ribs,
  scapula, clavicle
• in advanced labour, fetal hand and arm may
  prolapse into the vagina

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MANAGEMENT

• Consider ECV prior to labour
• if diagnosed in labour,deliver by Caesarean
  section (as fetal head and trunk would have to
  enter pelvis at the same time to deliver
  vaginally)
• Caesarean may need to be classical, as lower
  segment often inadequate

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COMPOUND PRESENTATION

• Incidence 0.1
• Mechanics of presentation
• When a fetal extremity prolapses alongside the
  presenting part, and both enter the maternal
  pelvis at the same time
• vertex-hand
• breech-hand
• vertex-arm-foot
• Aetiology
• Fetal
• multiple
• premature
• Maternal
• multiparity

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MANGEMENT

• Exclude cord prolapse
• occurs in up to 20 of cases
• Otherwise expectant
• mostly doesnt interfere with normal delivery
• vertex-foot try to gently reposition the lower
  extremity
• if arm prolapses in vertex-hand, wait and see if
  it moves as head descends if it converts to
  shoulder presentation, deliver by CS

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SUMMARY

• Abnormal lie, malpresentation, malposition
• Incidence, mechanics, aetiology, diagnosis,
  management of
• BREECH PRESENTATION
• FACE PRESENTATION
• BROW PRESENTATION
• SHOULDER PRESENTATION
• COMPOUND PRESENTATION