MalpresentationMalpresentation

Dr. Abdalla H. ElsadigDr. Abdalla H. Elsadig

MDMD

DefinitionsDefinitions

PresentationPresentation::

Is the lowermost part of the fetus occupying the lower uterine Is the lowermost part of the fetus occupying the lower uterine segment ( cephalic, breech, hand, cord… etc). segment ( cephalic, breech, hand, cord… etc).

Malpresentation:Malpresentation:

includes all presentations other than cephalic.includes all presentations other than cephalic.

Why malpresentation?Why malpresentation?

In vertex presentationIn vertex presentation the presenting part is a typical sphere the presenting part is a typical sphere (9.5 X 9.5 cm); this sphere will allow:(9.5 X 9.5 cm); this sphere will allow:

• Production of equal uterine contraction → efficient uterine Production of equal uterine contraction → efficient uterine contractions.contractions.

• Production of equal cervical dilatation → well fitting Production of equal cervical dilatation → well fitting presenting part.presenting part.

• The membrane remain intact for a long time (6-8 cm).The membrane remain intact for a long time (6-8 cm).• The cord will not prolapse.The cord will not prolapse. In malpresentationIn malpresentation: the presenting part is irregular, not fitting : the presenting part is irregular, not fitting

well to the cervix → complications during labour.well to the cervix → complications during labour.

Breech Presentation

Incidence: at term 3-4%, at 32 weeks 15% and at 28 weeks 20%.

Types of breech:

1. extended or frank (60-70%): the thighs are flexed at hip joints and the legs are extended the knee joints.

2. Complete or flexed (25%): The thighs and legs are flexed at hip and knee joints

3. Incomplete (10%): The fetal foot or knee is the lowermost presenting part

Etiology of breech presentationEtiology of breech presentation:

Preterm delivery (major reason)Maternal factors:

• Uterine anomalies: bicornate…• Pelvic mass: fibroids…

ovarian...• Anticonvulsant therapy.• Drug /alcohol abuse.

Fetal factors:• IUGR/death.• Congenital anomalies (esp. CNS): - anencephaly/hydrocephalus - Myelomeningocele. - prader-Willi syndrome

Feto-maternal factors:• Preterm delivery.• Placenta praevia• Multiple gestation• Previous history of breech

delivery.• Polyhydramnios/

oligohydramnios.

Diagnosis of breech presentation

Abdominal palpationAbdominal palpation:: Fetal heart auscultationFetal heart auscultation::

Ultrasound:Ultrasound: Vaginal examinationVaginal examination::• Frank breech:Frank breech:

- Ischial tuberosities, the sacrum - Ischial tuberosities, the sacrum and anus are palpable and anus are palpable

• Complete breechComplete breech

- Feet are felt along side the - Feet are felt along side the buttock.buttock.

• Footling:Footling:

- foot or knee is presenting- foot or knee is presenting

Management of breech presentationManagement of breech presentation

Antenatal managementAntenatal management::• Fetal an d maternal assessment.Fetal an d maternal assessment.• External cephalic version.External cephalic version. Breech deliveryBreech delivery::

When?When? (Time of delivery): (Time of delivery): Term/preterm delivery.Term/preterm delivery.

How?How? (Mode of delivery): (Mode of delivery): Vaginal delivery:Vaginal delivery:• Spontaneous breech delivery• Assisted breech delivery• Breech extraction Caesarean sectionCaesarean section

Antenatal managementAntenatal management

External cephalic version:

• Benefits: 97.5% success rate.97.5% success rate.

• IndicationsIndications:: uncomplicated breech uncomplicated breech presentation after 37 week’s gestation.presentation after 37 week’s gestation.

• Absolute contraindicationsAbsolute contraindications::

- multiple pregnancy – APH - multiple pregnancy – APH

- Ruptured membrane. - Ruptured membrane.

- fetal abnormalities.- fetal abnormalities.

- cord around the neck. - cord around the neck.

• Relative contraindicationsRelative contraindications:: - previous C/S – maternal disease.- previous C/S – maternal disease.

- maternal obesity BMI > 20% of the ideal. - maternal obesity BMI > 20% of the ideal.

• Risks of ECV:Risks of ECV:• Procedure of ECVProcedure of ECV::

Vaginal breech deliveryVaginal breech delivery

Criteria:• Frank or complete breech presentation with gestational age >

36 weeks.• Estimated fetal weight of 2.5-3.5 kg.• flexed fetal head. Extended head (due to nuchal cord, fundal

placenta, neck muscle spasm, uterine abnormalities) associated with > 90% poor prognosis.

• Adequate maternal pelvis (Multiparous).• No other obstetric complications: previous C/S, PET, diabetes,

IUGR,…..etc.• Preferably epidural analgesia.• Well trained staff and equipped hospital.

Procedure of breech delivery

Types of vaginal breech delivery:

• Spontaneous breech delivery

• Assisted breech delivery

• Breech extraction

Procedure of breech delivery

First stage of labor

- maternal and fetal monitoring

- C/S if failure of progress or Fetal distress

- Anaethesia (epidural). - Oxytocin (? No)

Procedure of breech delivery

Second stage of labor:-lithotomy position –episiotomy -Spontaneous up to umbilicus -Rotation to sacro-anterior. - pressure on popliteal fossa. -Cord is brought down. -Allow fetus to hang till to

see posterior scapular - Deliver anterior schoulder or - Lovset’s manoevre.

Procedure of breech delivery

Delivery of posterior arm

Procedure of breech delivery

Delivery of the head- Mauriceau-Smellie-Veit

maneuver

Procedure of breech delivery

Delivery of the headForceps delivery

Complications of breech deliveryComplications of breech delivery

Fetal complicationsFetal complications: : • Intracranial haemorrhageIntracranial haemorrhage• hypopiturarism.hypopiturarism.• Medullary coning Medullary coning • spinal cord severance.spinal cord severance.• Brachial plexus injuryBrachial plexus injury• fracture of long bonefracture of long bone• rupture of internal organsrupture of internal organs• amage to male genitalia .amage to male genitalia .• Damage to mouth and Damage to mouth and

pharynx.pharynx.

• Occipital diastasis: Occipital diastasis: impaction of occipital bone impaction of occipital bone over pubic bone in second over pubic bone in second stage → separation of stage → separation of occipital bone , cerebellum occipital bone , cerebellum damage, brain tissue damage, brain tissue herniation through foramen herniation through foramen magnum, stillbirth or ataxic magnum, stillbirth or ataxic cerebral palsy.cerebral palsy.

Maternal complicationsMaternal complications::• Soft tissue injuriesSoft tissue injuries• Haemorrhage.Haemorrhage.• infectionsinfections

A real Slides For vaginal Breech DeliveryA real Slides For vaginal Breech Delivery

No action

No action

episiotomy

episiotomy

Perineum support

Buttocks delivery

Buttocks delivery

Legs delivery

Let baby to hang on weight

Anterior arm delivery

posterior arm delivery

Burn-Marshal manoeuvre

Burn-Marshal manoeuvre

Burn-Marshal manoeuvre

Third stage of labour