MALPRESENTATION

&MALPOSITION&MALPOSITION

LECTURE OVERVIEW

Abnormal lie, malpresentation and malpositionAbnormal lie, malpresentation and malposition Malpresentation and its managementMalpresentation and its management

breechbreech faceface browbrow shouldershoulder compoundcompound

DEFINITIONS

Abnormal lieAbnormal lie where the long axis of the fetus is notwhere the long axis of the fetus is not

lying lying along the long axis of the motheralong the long axis of the motherLONGITUDINAL (MAY BE EITHER LONGITUDINAL (MAY BE EITHER

CEPHALIC OR BREECH)CEPHALIC OR BREECH)TRANSVERSETRANSVERSEOBLIQUEOBLIQUEUNSTABLEUNSTABLE

DEFINITIONS

MalpresentationMalpresentation where the fetus is lying longitudinally, but where the fetus is lying longitudinally, but

presentspresents in any manner other than vertex in any manner other than vertexBREECHBREECHFACEFACEBROWBROWSHOULDERSHOULDERCOMPOUNDCOMPOUNDCORDCORD

DEFINITIONS

MalpositionMalposition where the fetus is lying longitudinally where the fetus is lying longitudinally

and the vertex is presenting, but it is not and the vertex is presenting, but it is not in the OA in the OA positionpositionOT (LOT, ROT)OT (LOT, ROT)OPOP

DEFINITIONS

MalpresentationMalpresentation where the fetus is lying longitudinally, but where the fetus is lying longitudinally, but

presentspresents in any manner other than vertex in any manner other than vertexBREECHBREECHFACEFACEBROWBROWSHOULDERSHOULDERCOMPOUNDCOMPOUNDCORDCORD

MANAGEMENT OF BREECH PRESENTATION AT TERM

Management optionsManagement options

(1) external cephalic version(1) external cephalic version

(2) elective caesarean section(2) elective caesarean section

(3) trial of vaginal delivery(3) trial of vaginal delivery

EXTERNAL CEPHALIC VERSION

CONTRAINDICTAIONS:CONTRAINDICTAIONS: 3rd trimester bleeding3rd trimester bleeding uterine anomaliesuterine anomalies ROM, oligohydramniosROM, oligohydramnios need for CS for other reasons (placenta praevia, need for CS for other reasons (placenta praevia,

contracted pelvis, hyperextended head)contracted pelvis, hyperextended head) indicated vaginal delivery (fetal death, anomaly indicated vaginal delivery (fetal death, anomaly

best delivered as breech)best delivered as breech)

EXTERNAL CEPHALIC VERSION

SUCCESSSUCCESS 60-70%60-70%

TECHNIQUETECHNIQUE after 36Wafter 36W CTG priorCTG prior attempt to perform forward somersaultattempt to perform forward somersault tocolytictocolytic CTG after (8% bradycardia; 5% fetomaternal CTG after (8% bradycardia; 5% fetomaternal

haemorrhage)haemorrhage) anti D (if Rh negative)anti D (if Rh negative)

ELECTIVE CAESAREAN SECTION

EFW <2500g; >3500gEFW <2500g; >3500g preterm breechpreterm breech hyperextended fetal headhyperextended fetal head palcenta praeviapalcenta praevia concerns re. fetal well being, including oligohydramniosconcerns re. fetal well being, including oligohydramnios footling breechfootling breech

10% risk of cord prolapse10% risk of cord prolapse ?complete breech?complete breech

5% risk of cord prolapse (c.f. 1% with frank breech)5% risk of cord prolapse (c.f. 1% with frank breech) ?all PG breech?all PG breech

CRITERIA FOR VAGINAL DELIVERY

Frank or complete breechFrank or complete breech EFW 2500-3500gEFW 2500-3500g gestational age >36 weeksgestational age >36 weeks fetal head must be flexedfetal head must be flexed maternal pelvis must be adequatematernal pelvis must be adequate

judged clinically or by pelvimetryjudged clinically or by pelvimetry no other maternal or fetal indiaction for CSno other maternal or fetal indiaction for CS experienced obstetrician, anaesthetist and paediatrician experienced obstetrician, anaesthetist and paediatrician

present at deliverypresent at delivery

FACE PRESENTATION Incidence:Incidence: 0.2% 0.2% Mechanics of presentation:Mechanics of presentation:

Characterized by extreme extension of the fetal head so the face Characterized by extreme extension of the fetal head so the face (rather than the skull) presents to the birth canal(rather than the skull) presents to the birth canal

AetiologyAetiology any factor that favours extension such as fetal goitre, any factor that favours extension such as fetal goitre,

anencephalyanencephaly high maternal parity high maternal parity

At diagnosis:At diagnosis: 60% mentoanterior 60% mentoanterior 15% mentotransverse15% mentotransverse 25% mentoposterior25% mentoposterior

BROW PRESENTATION Incidence:Incidence: 1:1400 1:1400 Mechanics of presentation:Mechanics of presentation:

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

usually usually transitionaltransitional- when the head is in the process of - when the head is in the process of converting from a vertex to a face or vice versaconverting from a vertex to a face or vice versa

presenting part is between the facial orbits and anterior presenting part is between the facial orbits and anterior fontanellefontanelle

supraoccipitomental diameter is presenting 13.5cm; cf supraoccipitomental diameter is presenting 13.5cm; cf 9.5cm for suboccipitobregmatic (vertex) or 9.5cm for suboccipitobregmatic (vertex) or submentobregmatic (face)submentobregmatic (face)

AETIOLOGY FetalFetal

prematurity, multipleprematurity, multiple LiquorLiquor

polyhydramniospolyhydramnios UterineUterine

anomalyanomaly PlacentaPlacenta

praeviapraevia PelvisPelvis

contraction, tumourcontraction, tumour ParityParity

high maternal parity (80% of cases occur in women who are high maternal parity (80% of cases occur in women who are para3 or more)para3 or more)

MANGEMENT

Exclude Exclude cord prolapsecord prolapse occurs in up to 20% of casesoccurs in up to 20% of cases

Otherwise Otherwise expectantexpectant mostly doesn’t interfere with normal deliverymostly doesn’t interfere with normal delivery vertex-foot: try to gently reposition the lower vertex-foot: try to gently reposition the lower

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

it moves as head descends; if it converts to it moves as head descends; if it converts to shoulder presentation, deliver by CSshoulder presentation, deliver by CS

SUMMARY

Abnormal lie, malpresentation, malpositionAbnormal lie, malpresentation, malposition Incidence, mechanics, aetiology, diagnosis, Incidence, mechanics, aetiology, diagnosis,

management ofmanagement of BREECH PRESENTATIONBREECH PRESENTATION FACE PRESENTATIONFACE PRESENTATION BROW PRESENTATIONBROW PRESENTATION SHOULDER PRESENTATIONSHOULDER PRESENTATION COMPOUND PRESENTATIONCOMPOUND PRESENTATION