Defintion

Fetal presenting part other than vertex includes breech, face, brow, transverse, and compound presention.

Definition

More than one pregnancy (e.g. Multipara,Grand multipara )More than one fetus (e.g. Twins)Too much or too little amniotic fluid (e.g.

Poly hydramnious, oligohydramnios) Abnormal uterine shape (e.g.

Arcuate ,septate, supseptate) or abnormal growth (e.g Fibroid)

Placenta previa The baby is preterm

Related Factors

Defintion• Breech 3 in 100 (3%)• Face 1 in 500 (0.5%)• Brow 1 in 2000 (0.02%)• Shoulder 1 in 300 (0.3%)• Compound 1 in 5000 ( 0.05%)

Incidence of malpresentation

Shoulder presentation

It is a Transverse lie

in which the long axis of the

fetus is perpendicular( 900)

to long axis of mother.Shoulder of baby comes in– the lower segment of uterus(0.5%)

4 position in Shoulder presentation Acrimon- anterior(60%) Left Right Acrimo- posterior(40%) Right Left Acrimo anterior position is more common as the

concavity of front of fetus fix in convexity of maternal spine

Placenta is posterior in 60% of cases

Lt Acrimoanterior Rt Acrimoanterior

Rt Acrimoposterior Lt Acrimoposterior

Diagnosis

Abdominal examination,the head is usually felt in one

iliac fossa or in the flank.

The breech in the other iliac fossa but at a higher level

Fundal level just above umbilicus

FH sound heard below the umbilicus

On vaginal examination

Early in laborthe cervix is elevatedlower uterine segment is imperfectly filledLate in labor The cervix is sufficiently dilated: We can feel:

scapula, acromion, clavicle, axilla and ribsConfirm position: If the arm is prolapsed

and supinated the dorsum points to the back and the thumb points to the head.

Neglected shoulder

Prolonged laborMembrane ruptured liquor drained Arm may be prolapsedFetus dead or dyingLower segment overstretchedSigns and symptoms of obstructed labor

Management

During pregnancyA-External cephalic version Can be tried up to full term,Even early in labour before ROM

* Laxity of the abdominal & uterine walls makes the procedure easier than in breech

* The fetus will be rotated only 90 degrees. B. If fails, do external podalic version.

head.

During labor

External cephalic version (ECV) is tried with intact membranes :

- If succeeded: Rupture of membranes and application of

abdominal binder. - If failed: C.S. is the safest for the mother & fetus.

If the membranes are ruptured before full cervical dilatations do C.S.

Management

In modern practice, persistent transverse lie in labor is delivered by caesarean section whether the fetus is alive or dead

Face Presentation

head is hyper extended

presenting part is face

- denominator is chin(mentum) between glabella & chin

presenting diameter is submentobregmatic (9.5cm)

Types of Face Presentation

2ry face (during labor) commen

The majority of cases of face are secondary to occipto-posterior which transformed to mento anterior

Causes are maternal

1ry face (during pregnancy )rare Causes are fetal

AETIOLOGY

In Face presentation- 6 position

Lt mento-ant Rt mento-ant Rt mento-post

Diagnosis

The chin serves as the referenc point in describing the position of the head. It is necessary to distinguish chin-anterior positions in which the chin is anterior in relation to the maternal pelvis from chin-posterior positions.

Diagnosis

On abdominal examination, a groove may be felt between the occiput and the back.On vaginal examination Neither the occiput nor the sinciput are palpable

supra-orbital ridges, chin, alveolar margin ± ala nasi Confirm presention

Mechanism of labor in MA

The head descends with the submento-bregmatic diameter (9.5 cm).

Descent, engagement, increased extension of the head

the chin meets the pelvic floor first and rotates forwards 1/8 of a circle.

With further descent the submental-region hinges below the symphysis pubis

the head is delivered by flexion , followed by restitution and external rotation of the chin as in vertex presentation.

Mechanism of labor in MP

Normal mechanism: In 2/3 of cases the chin rotates forwards 3/8 of a circle and delivered as MA

Abnormal mechanism (In 1/3 of cases): The chin may rotate forwards 1/8 circle (deep transverse arrest of the face).

no rotation(persistent oblique MP). The chin rotate backwards 1/8 circle (direct MP)

Cervix fully dilated Cervix not fully

dilated

Allow normal child birthAllow normal child birth

Slow progress with no signs of obstruction

Slow progress with no signs of obstruction

Descent unsatisfactoryDescent unsatisfactory

Augmentation of labour

Augmentation of labour

Forceps delivery

Augmentation of labourAugmentation of labour

Management of Chin-anterior Management of Chin-anterior

It is a cephalic presentation with the head midway between flexion and extension.

Incidence: 1 /2000

The frontal bone is

the denominator.

There are 4 main positions

• - Left fronto-anterior. • - Right fronto-anterior.

• - Right fronto-posterior. • - Left fronto-posterior.

Types &Etiology of brow

Transient brow(2RY)• During conversion of vertex to face.Persistent brow(1RY) • Extremely rareEtiology: same as face

Mechanism of labour

Transient brow(2RY)

brow may be converted spontaneously into face (by extension) or vertex (by flexion) and this followed by spontaneous delivery

Persistent brow:

There is no mechanism

for delivery because the

head descends by the mento

-vertical diameter (13.5 cm)

which is longer than any

of the diameters of the pelvic inlet. So, the head become arrested at the

pelvic inlet ,and labour is obstructed.

Diagnosis

Abdominal examination: the occiput & sinciput are felt at the same level PV examinationfrontal bone, supra-orbital ridges and the root of the nose are felt.

Compound Presentation

Occurs when an extremity (usually an arm less commonly lower limb) prolepses alongside the presenting part.

• Both the prolapsed arm and the fetal head present in the pelvis simultaneously.

Diagnosis

Suspect compound presentation when

1.Active labor is arrested

2.The fetus fail to engage

3.The prolapsed extremity is palpated directly

ManagementDon’t manipulate the prolapsed extremityIn many cases the extremity will spontaneously

be pulled back and away from the presenting part.

Spontaneous delivery in 75% of vertex /upper extremity presentation

Do continuous FHR monitoring because of associated occult cord prolapse

Reduce the extremity if Prolapsed extremity prevent descent of

fetus gently reduce by pushing it upward above the pelvic brim and hold it until a contraction pushes the head into the pelvis. 

Do CS if Non reassuring FHR traceCord prolapsedFailure of labor to progress

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