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MALPRESENTATION

&MALPOSITION

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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 motherLONGITUDINAL (MAY BE EITHER

CEPHALIC OR BREECH)

TRANSVERSEOBLIQUE

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 notin 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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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 3500g

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 frankbreech)

?all PG breech

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CRITERIA FOR VAGINAL

DELIVERY

Frank or complete breech

EFW 2500-3500g

gestational age >36 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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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 birthcanal

Aetiology

any factor that favours extension such as fetal

goitre, anencephaly high maternal parity

At diagnosis:

60% mentoanterior

15% mentotransverse

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BROW PRESENTATION

Incidence: 1:1400

Mechanics of presentation:

head is extended such that attitude is halfwaybetween flexion (vertex) and hyperextension(face)

usually transitional- when the head is in theprocess of converting from a vertex to a face orvice versa

presenting part is between the facial orbits andanterior fontanelle

supraoccipitomental diameter is presenting13.5cm cf 9.5cm for subocci itobre matic

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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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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 lowerextremity

if arm prolapses in vertex-hand, wait and see ifit 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