BASIC CONCEPTS

PRESENTATION
Part of the fetus occupying the lower segment of the uterus
Cephalic (Head, 95%), Breech (Buttocks, 3-4%), Shoulder,
Cord, Compound.
Malpresentation is any presentation other than cephalic.
LIE
Relation of longitudinal axis of fetus to the mothers
longitudinal axis
Longitudinal (99%) Transverse Oblique

STATION
Relation between the lowest bony part of the presenting
part to the imaginary line between two ischial spines
-3, -2, -1, 0, +1, +2, +3 [if above line: -ve, if below line:
+ve]
Assessed through vaginal exam.
ENGAGEMENT
Passage of the widest diameter of the presenting part
through the pelvic inlet.
If <2 fingers needed to palpate fetal head in pelvic grip:
Engaged.
*Pelvic inlet: Upper border of symphysis pubis (ant), sacral
promontory (post), ileopectineal line of iliac crest (lateral).

POSITION
Relation between the dominator (bony landmark of the
fetus) to the internal pelvis.
8: Anteriorly (left, right, direct), Posteriorly (left, right,
direct), Transverse (left, right)
Most common: Left occipito-anterior.
Malposition is any position other than occipito anterior.
*Bony landmarks:
Vertex: Occipital
Face: Mental
Brow: Frontal
Shoulder: Scapula
Breech: Sacrum

FETAL ATTITUDE
Relation of fetus parts to each other
Well-flexed (normally), Extended

BREECH PRESENTATION
DEFINITION
CAUSES
DIAGNOSIS
Buttocks occupying
Maternal Causes: Nulliparity, Old age, Fibroid,
Hx: Subcostal pain (coz fetal head)
lower segment of
Polyhydroamnios, oligohydroamnios, Bicornuate Abd exam: Leopold maneuver solid ballotable
uterus.
/ septate uterus, Hx of breech, Uterine/pelvis
rounded mass in fundus; soft irregular mass in
Commonest
tumors.
pelvis.
malpresentation.
Fetal Causes: Prematurity, IUGR, Large babies,
Vaginal exam: 2 ischial tuberosities & tip of
Commonest cause is
Multiple gestations, Fetal abnormalities,
sacrum.
prematurity.
Congenital anomalies, Short umbilical cord,
US: Confirm dx, look placental site, uterine
Cephalo-pelvic disproportion.
abnormality, # of babies, liquor amount,
estimate fetal weight.
TYPES
FRANK @ EXTENDED
COMPLETE
FOOTLING
Hips flexed, knees
Feet present beside
Hip & knee extended in
extended.
buttocks. Both hips &
one or both sides.
Primigravida.
knees flexed.
Preterm singleton.
Multipara.
A] EXTERNAL CEPHALIC VERSION (ECV)
NOTES
METHOD
CONTRAINDICATIONS
COMPLICATION
S
Done at term
Prep her as if to do C-section NPO, cannula, conduct in Absolute: HTN, PET, Previous Labor, PROM,
(>37th wks)
OT, ultrasound, CTG.
2 C-sections, Multiple
Placental
coz may revert
Rotate the baby by direction of his nose until it becomes gestation with 1st twin
abruption,
to breech, or
cephalic.
breech, Abnormal CTG, HSV,
Cord
induce labor.
Repeat CTG.
Previa, Pt refusal.
compression &
Success rate
If Rh-ve mother, give antiD coz risk of fetomaternal
Relative: IUGR,
prolapsed,
60%.
hemorrhage.
Polyhydroamnios,
Fetal
Discharge waiting for spontaneous vaginal delivery.
oligohydroamnios, fetal
bradycardia.
anomaly.
B] ASSISTED VAGINAL BREECH DELIVERY
C] CAESEREAN SECTION
CRITERIA
ASSISTANCE
Absolute Indications:
Prematurity, Footling breech.
Normal baby weight 2.5-3.5kg
After delivery of buttocks, 1) Episiotomy
Superior to vaginal breech
>36wks GA. Good pelvimetry (roomy
2) Keep fetal back anterior
delivery.
pelvis). Fetal head flexed, Breech type
After appearance of scapula 3) Rotate 90 to

Frank or Complete. Experienced

obstetrician. Anethetist (Epidural), No
other indications for C-section,
Multiparous, Normal labor progress,
Uncomplicated pregnancy.

deliver anterior shoulder & vice versa.

After visible hair line 4) Either Liverpool
maneuver, or Mauriceau-Smellie-Veit maneuver
or forceps delivery.

FACE & BROW PRESENTATIONS

FACE
Vaginal Exam: Nose, cheeks, mouth.
Commonly misdiagnosed as breech.
TYPES
MENTO-ANTERIOR

Presenting
diameter: 9.5cm.
MENTOPOSTERIOR

MANAGEMENT
If fully dilated
Allow vaginal
delivery.
If not fully dilated
Can augment
labor with
oxytocin.
COMMON NOTES
Never attempt to
convert face to
vertex.
Never apply
vacuum.
Can use forceps.
Can augment with
syntocinon.
Large episiotomy.

BROW
Vaginal exam: Orbital
ridges & nose.

CAUSES
Grand
multiparous
Neck swelling
(cystic
hygroma, goiter
etc)
Anencephaly

SHOULDER PRESENTATION
Transverse or oblique lie.
Abd Exam: Head in one flank & buttock
in another. No vaginal exam till R/O
previa.
CAUSES
Placenta previa, Prematurity,
Polyhydroamnios, Multiple pregnancy,
Abnormal uterus, Fibroid, Cervical
cancer, Contracted pelvis, Relaxed ab
wall.
MANAGEMENT: C-section

Presenting diameter:
13cm.
C-section. Never
vaginal delivery.

If fully dilated Csection.

If not fully dilated
Monitor for
conversion into
vertex
presentation.
If fetus dead
Craniotomy.
Presenting
diameter: 13cm.

DEFINITION
Umbilical cord as the
presenting part, below any
part of the fetus.
Coz ill-fitting presenting part
into lower segment of uterus
cord can go into space
below presenting part mainly
when footling breech or
AROM.

UMBILICAL CORD PROLAPSE

RISK FACTORS
CONSEQUENCES
Multiparity
Cord compression &
Prematurity
Vasospasm Cutting
Macrosomia
blood from fetus Fetal
Breech
distress.
Polyhydroamnios
Outcome depends on GA
& duration of
compression.

MANAGEMENT
Emergency C-section
Vaginal delivery only if delivery is imminent
(when vaginal quicker than c-section: fully
dilated & presenting part very low)
While waiting for C-section
- Fill bladder with 1L
- Push presenting part up
- Tredelenburg position