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Fetal Malpresentation
Fetal Malpresentation
Fetal malpresentation refers to fetal presenting part other than vertex and includes
breech, transverse, face, brow, and sinciput. Malpresentations may be identified late in
pregnancy or may not be discovered until the initial assessment during labor.
Related Factors
• The woman has had more than one pregnancy
• There is more than one fetus in the uterus
• The uterus has too much or too little amniotic fluid
• The uterus is not normal in shape or has abnormal growths, such as fibroids
• placenta previa
• The baby is preterm
Types of Malpresentation
1. BREECH (4%)
Complete (Flexed) Breech Presentation
Footling Breech Presentation
Frank (Extended) Breech Presentation
Kneeling Breech Presentation
2. VERTEX (95%)
Brow Presentation
Face Presentation
Sincipital Presentation
3. TRANSVERSE (1%)
On abdominal palpation the fetal head is found above the mother’s umbilicus as a
hard, smooth, rounded mass, which gently ‘ballots’ (can be rocked) between your
hands.
Why do you think a mass that ‘ballots’ high up in the abdomen is a sign of breech
presentation?
The baby’s head can ‘rock’ a little bit because of the flexibility of the baby’s neck, so
if there is a rounded, ballotable mass above the mother’s umbilicus it is very likely to be the
baby’s head. If the baby was ‘bottom-up’ (vertex presentation) the whole of its back will
move of you try to rock the fetal parts at the fundus
Once the fetus has engaged and labour has begun, the breech baby’s buttocks can be
felt as soft and irregular on vaginal examination. They feel very different to the
relatively hard rounded mass of the fetal skull in a vertex presentation. When the
fetal membranes rupture, the buttocks and/or feet can be felt more clearly. The
baby’s anus may be felt and fresh thick, dark meconium may be seen on your
examining finger. If the baby’s legs are extended, you may be able to feel the
external genitalia and even tell the sex of the baby before it is born.
Fetal heart tone auscultation: Breech Fetal heart best heard above Umbilicus
Cervical examination
No hard head palpated in Pelvis
Fontanels and Sutures not palpable
Soft buttocks palpated with hard irregular Sacrum
Skin of buttocks is smooth
Feet may be presenting part in Pelvis
Types of Malpresentation
A. BREECH
Breech presentation means that either the buttocks or the feet are the first body
parts that will contact the cervix.
Breech presentations occur in approximately 3% of the births and are affected by
fetal attitude.
Breech presentations can be difficult births, with the presenting point influencing
the degree of difficulty.
Risk Factors: Prematurity; Multiple prior pregnancies; Polyhydramnios or oligohydramnios; Uterine
abnormalities; Fetal abnormalities (e.g. Down Syndrome, Hydrocephalus); Macrosomia; Twin Gestation;
Breech Presentation in prior pregnancy; Absolute Cephalopelvic Disproportion
2. Footling Breech
One or both feet come first, with the
bottom at a higher position. This is rare at
term but relatively common with
premature fetuses.
4. Kneeling Breech
The baby is in a kneeling position, with one or both legs extended at the hips and flexed
at the knees. This is extremely rare.
Maternal Risks
Prolonged labor r/t decreased pressure exerted by the breech on the cervix.
PROM may expose client to infection.
Cesarean or forceps delivery.
Trauma to birth canal during delivery from manipulation and forceps to free the
fetal head.
Intrapartum or postpartum hemorrhage.
Fetal Risks:
Compression or prolapse of umbilical cord.
Entrapment of fetal head in incompletely dilated cervix.
Aspiration and asphyxia at birth.
Birth trauma from manipulation and forceps to free the fetal head.
Management
a. If the woman is in early labor and the membranes are intact, attempt External
Cephalic Version. ECV involves the lifting of the fetal bottom with one hand whilst
the fetal head is pushed down with the other, moving the fetus in an anti-
clockwise direction.
b. Tocolytics, such as Terbutaline 0.25 mg IM, can be used before ECV to help relax the
uterus.
c. If ECV is successful, proceed with normal childbirth. If EVC fails or is not advisable,
deliver by caesarean section.
Attempting ECV at term reduces the risk of a non-cephalic birth and caesarean
section.
Success rates of ECV range between 30-80%. Factors contributing to successful ECV
include: multiparity, non-white race, relaxed uterine tone, adequate liquor volume
and a station above the pelvic brim.
ECV is a safe procedure that has been shown not to increase the risk of intrauterine
death within and after 24 hours of the procedure, irrespective of the outcome of
ECV.
Complications associated with ECV are uncommon but include placental
abruption,uterine rupture and fetomaternal haemorrhage.
It should only be carried out by appropriately trained practitioners where facilities
for continuous fetal monitoring, ultrasound and emergency caesarean delivery are
available.
A cesarean section is safer than vaginal breech delivery and recommended in cases of:
Double footling breech
Small or malformed pelvis
Very large fetus
Previous cesarean section for cephalopelvic disproportion
Hyperextended or deflexed head.
B. TRANSVERSE
In a transverse lie, a fetus lies horizizontally in the pelvis so that the longest fetal
axis is perpendicular to that of the mother.
The presenting part is usually one of the shoulders (acromion process), an iliac crest,
a hand, or an elbow.
Shoulder Presentation
Occurs when fetus is transverse with back down
Shoulder sits over pelvic inlet
Do not attempt to turn a sideways lying baby. Unless a trained physician or midwife can turn the baby
‘head down’, it must be delivered by caesarean surgery.
Causes of shoulder presentation
Causes of shoulder presentation could be maternal or fetal factors.
Maternal factors include: Lax abdominal and uterine muscles: most often after several
previous pregnancies; Uterine abnormality; Contracted (abnormally narrow) pelvis.
Fetal factors include: Preterm labour; Multiple pregnancy; Polyhydramnios; Placenta
previa.
Remember that a shoulder presentation means the baby cannot be born through the
vagina; if you detect it in a woman who is already in labour, refer her urgently to a higher
health facility.
In all cases of malpresentation or malposition, do not attempt to turn the baby with your hands!
Only a specially trained doctor or midwife should attempt this. Refer the mother so she and her
baby can get emergency obstetric care.
C. SINCIPUT D. FACE
The sinciput presentation occurs The face presentation is caused
when the larger diameter of the by hyper-extension of the fetal
fetal head is presented. Labor head so that neither the occiput
progress is slowed with slower nor the sinciput is palpable on
descent of the fetal head. vaginal examination.
FacePresentation
Incidence is about 1in 500births
Causes:-
In many cases there is no obvious cause
Anencephaly (10%)
prematurity (25%)
multiple pregnancy.
loops of cord around the neck and
a swelling in the neck such as goitre or cystic hygroma
Management
In the chin-anterior position prolonged labor is common. Descent and delivery of
the head by flexion may occur.
In the chin-posterior position, however, the fully extended head is blocked by the
sacrum. This prevents descent and labor is arrested.
Management
Chin-Anterior Position
If the cervix is fully dilated: Chin-Posterior Position
Allow to proceed with If the cervix is fully dilated:
normal childbirth; Deliver by caesarean
If there is slow progress section.
and no sign of obstruction, If the cervix is not fully dilated
augment labor with Monitor descent, rotation
oxytocin; and progress. If there are
If descent is unsatisfactory, signs of obstruction, deliver
deliver by forceps. by caesarean section.
If the cervix is not fully dilated and there *Do not perform vacuum extraction for
are no signs of obstruction: face presentation.
augment labor with
oxytocin.
Complications of face presentation
Complications for the fetus include:
Obstructed labour and ruptured uterus
Cord prolapse
Facial bruising
Cerebral haemorrhage (bleeding inside the fetal skull).
F. BROW
The brow presentation is caused by partial extension of the fetal head so that the
occiput is higher than the sinciput. Incidence about 1:1000 births.
Diagnosis:- On P.V the supra –orbital ridges and anterior fontanelle are palpable but not
the nose ,mouth or chin.
On abdominal examination, the head is high in the mother’s abdomen, appears
unduly large and does not descend into the pelvis, despite good uterine contractions. On
vaginal examination, the presenting part is high and may be difficult to reach. You may be
able to feel the root of the nose, eyes, but not the mouth, tip of the nose or chin. You may
also feel the anterior fontanel, but a large caput (swelling) towards the front of the fetal
skull may mask this landmark if the woman has been in labour for some hours.
G. COMPOUND PRESENTATION
One or more limbs present with the head or the breech . most commonly a hand
with the vertex .
A fetal position during delivery in which there are multiple fetal body parts that
descends down the birth canal along with the main presenting part. Usually, this
includes usually an extremity.
The commonest cause is prematurity , others are contracted pelvis , pelvic tumour ,
poly hydramnios and dead fetus. -The main complcation is prolapse of the cord
Signs
1. Digital cervical exam
1. Hand palpated beside presenting fetal head
Differential Diagnosis
2. Fetal foot beside head
Management
Expectant management
1. Vaginal Delivery usually occurs
Consider repositioning if descent arrested
a. Elevate fetal hand
b. Bring head downward
2. Fear
Provide client and family teaching,
Note for degree of incapacitation.
Stay with the client or make arrangements to have someone else be there.
Provide opportunity for questions and answer honestly.
Explain procedures within level of client’s ability to understand and handle.