MAL-PRESENTATION AND MAL-POSITION

INTRODUCTION

fetal malpresentation occurs when the part of the fetus which is closest to the pelvic inlet is
not the vertex of the fetal head, whereas fetal malposition occurs when the occiput of fetuses
who are in vertex presentation is rotated so that it is not oriented anteriorly in the maternal
pelvis.

Definitions

q presentation - refers to the fetal anatomic part which is the first part to proceed into
and through the pelvic inlet

q fetal lie - describes the relationship between the long axis of the fetus and the long
axis of the mother

q fetal position - describes the orientation of the fetal presenting part relative to the
pelvis of the mother

q fetal presenting part - refers to the part of the fetus which is the first to proceed into
and through the pelvic inlet

q fetal vertex - refers to area defined between anterior fontanel and posterior fontanel

q vertex presentation - fetal vertex is presenting part

q malpresentation - occurs when the fetal presenting part is other than the fetal vertex

q persistent - when malposition or presentation is maintained during second stage of

labor and until delivery.

Types of Fetal Malpresentations

Fetal malpresentations types include;

1. Breech - most common malpresentation; buttocks or feet of fetus are fetal presenting
part

Ø frank breech - hips flexed and legs extended over anterior surface of body

Ø complete breech - feet presenting but flexed hips and knees

Ø footling breech

 at least 1 extended fetal hip

  contraindication to labor

2. Transverse/Oblique Lie - often results in shoulder or arm presentation

in transverse lie, the shoulder is typically over the pelvic inlet, the fetal head typically lies in
1 maternal iliac fossa, and the breech lies in the other

further classified based on;

 which maternal side the fetal acromion rests (right or left acromial)

 position of the fetal back (dorsoanterior or dorsoposterior)

3. Sinciput presentation

 front part of head is presenting part

 fetal head is neither flexed nor extended

4. Face and Brow Presentation

q fetus is cephalic presenting but the fetal neck is extended so that the fetal brow or face
present rather than the vertex

q brow presentation occurs when the fetal head is partially extended

q face presentation occurs when the fetal head is completely extended

q vertex presentation occurs, in comparison, when the fetal head is completely flexed

5. Compound Presentation - occurs when there is an extremity preceding or adjacent to the

presenting fetal head

6. Asynclitism - occurs when a cephalic fetus has its head bent toward its shoulder causing
malalignment of the central axes of the fetal head and maternal pelvis

 anterior asynclitism results from anterior tilting of the fetal head (most common)

 posterior asynclitism occurs with posterior tilting of the fetal head (rare)

TYPES OF FETAL MALPOSITION

1. Occiput Posterior - fetal occiput is oriented toward the posterior aspect of the maternal
pelvis

Ø direct occiput posterior - occiput is posterior and does not deviate from the midline
of the maternal pelvis
 Ø right occiput posterior

o occiput is posterior but deviates from the midline of the maternal pelvis up to
45 degrees to the right

o observed more frequently than left occiput posterior and direct occiput in the
second stage of labor

Ø left occiput posterior

o occiput is posterior but deviates from the midline of the maternal pelvis up to 45
degrees to the left

o observed more frequently than right occiput posterior and direct occiput posterior in
the first stage of labor

2. Occiput Transverse - fetal sagittal suture and fontanels are aligned in the transverse
maternal pelvis

Ø right occiput transverse - occiput is transverse but deviates from the midline of the
maternal pelvis up to 45 degrees to the right

Ø left occiput transverse - occiput is transverse but deviates from the midline of the
maternal pelvis up to 45 degrees to the left

Normal Fetal Presentation and Positioning

Ø fetuses who are in cephalic lie, vertex position, and occiput anterior position are most
likely to deliver vaginally.

Ø when the fetal head is flexed and the vertex is occiput anterior, the effective fetal head
diameter is minimized and the presenting shape of the fetal head is optimized to fit
through the maternal pelvis.

Ø it is common for vertex-presenting fetuses to be occiput transverse during early labor,

but most spontaneously rotate to occiput anterior during labor.

BLEEDING

Bleeding, also called hemorrhage, is the name used to describe blood loss. It can refer to
blood loss inside the body, called internal bleeding, or to blood loss outside of the body,
called external bleeding.
Blood loss can occur in almost any area of the body. Internal bleeding occurs when blood
leaks out through a damaged blood vessel or organ. External bleeding happens when blood
exits through a break in the skin.

Blood loss from bleeding tissue can also be apparent when blood exits through a natural
opening in the body, such as the:

 mouth

 vagina

 rectum

 Nose

TYPES OF BLEEDING

There are three main types of bleeding:

1. capillary,

2. venous, and

3. arterial bleeding.

The main difference between the three is the type of blood vessels where hemorrhaging
occurs, which can impact severity.

Arterial bleeding occurs in the arteries, which transport blood from the heart to the body.
Venous bleeding happens in the veins, which carry blood back to the heart. Capillary
bleeding takes place in the capillaries, which are tiny blood vessels that connect the arteries to
the veins.

ANAEMIA

Anemia is defined as a low number of red blood cells. In a routine blood test, anemia is
reported as a low hemoglobin or hematocrit. Hemoglobin is the main protein in your red
blood cells. It carries oxygen and delivers it throughout your body. If you have anemia, your
hemoglobin level will be low, too. If it is low enough, your tissues or organs may not get
enough oxygen. Symptoms of anemia – like fatigue or shortness of breath – happen because
your organs aren't getting what they need to work the way they should.

TYPES OF ANEMIA

There are many anemia types, each causing red blood cell levels to drop.
 Nutritional anemias

o Pernicious anemia: Pernicious anemia, one of the causes of vitamin B12 deficiency, is an
autoimmune condition that prevents your body from absorbing vitamin B12.

o Iron-deficiency anemia: As its name implies, iron-deficiency anemia happens when your
body doesn’t have enough iron to make hemoglobin. Hemoglobin is the substance in your red
blood cells that enables them to carry oxygen throughout your body.

o Megaloblastic anemia: Megaloblastic anemia is a type of vitamin deficiency anemia that

happens when you don’t get enough vitamin B12 and/or vitamin B9 (folate).

Inherited anemias

o Sickle cell anemia: Sickle cell anemia changes your red blood cells’ shape, turning round
flexible discs into stiff and sticky sickle cells that block blood flow.

o Fanconi anemia: Fanconi anemia is a rare blood disorder. Anemia is one sign of Fanconi
anemia.

o Diamond-Blackfan anemia: This inherited disorder keeps your bone marrow from making
enough red blood cells.

Anemias caused by abnormal red blood cells

o Hemolytic anemia: In this anemia, your red blood cells break down or die faster than usual.

o Aplastic anemia: This anemia happens when stem cells in your bone marrow don’t make
enough red blood cells.

o Autoimmune hemolytic anemia: In autoimmune hemolytic anemia, your immune system

attacks your red blood cells.

o Sideroblastic anemia: In sideroblastic anemia, you don’t have enough red blood cells and you
have too much iron in your system.

o Macrocytic anemia: This anemia happens when your bone marrow makes unusually large red
blood cells.

o Microcytic anemia: This anemia happens when your red blood cells don’t have enough
hemoglobin so they’re smaller than usual.

o Normocytic anemia: In this type of anemia, you have fewer red blood cells than usual, and
those red blood cells don’t have the normal amount of hemoglobin.
CAUSES OF ANEMIA

People may be born with certain types of anemia or develop anemia because they have
certain chronic diseases. But poor diet causes iron-deficiency anemia, which is the most
common form of anemia.

SYMPTOMS OF ANAEMIA

The signs of anemia can be so mild that you might not even notice them. At a certain point,
as your blood cells decrease, symptoms often develop. Depending on the cause of the anemia,
symptoms may include:

 Dizziness, lightheadness, or feeling like you are about to pass out

 A fast or unusual heartbeat

 A headache

 Pain, including in your bones, chest, belly, and joints

 Problems with growth, for children and teens

 Shortness of breath

 Skin that’s pale or yellow

 Cold hands and feet

 Tiredness or weakness

Treatment

Treatment for anemia depends on its cause. Common approaches include iron supplements
for iron-deficiency anemia, vitamin B12 injections for pernicious anemia, and addressing
underlying conditions. A balanced diet rich in iron, vitamins, and minerals can also support
recovery. Consult a healthcare professional for personalized advice based on your specific
type of anemia.

MULTIPLE PREGNANCY

A multiple pregnancy is a pregnancy where you’re carrying more than one baby at a time. If
you’re carrying two babies, they are called twins. Three babies that are carried during one
pregnancy are called triplets. You can also carry more than three babies at one time (high-
order multiples). There are typically more risks linked to a multiple pregnancy than a
singleton (carrying only one baby) pregnancy.
CAUSES OF MULTIPLE PREGNANCY

The use of fertility drugs to induce ovulation often causes more than one egg to be released
from the ovaries and can result in twins, triplets, or more.

In vitro fertilization (IVF) can lead to a multiple pregnancy if more than one embryo is
transferred to the uterus. Identical multiples also may result if the fertilized egg splits after
transfer.

Women older than age 35 are more likely to release two or more eggs during a single
menstrual cycle than younger women. So older women are more likely than younger women
to become pregnant with multiples.

symptoms of multiple pregnancy

Women who are pregnant with multiples may have more severe morning sickness or breast
tenderness than women who are pregnant with a single fetus. They also may gain weight
more quickly. Most multiple pregnancies are discovered during an ultrasound exam.

Common Complication of Multiple Pregnancy

The most common complication of multiple pregnancy is preterm birth. More than one half
of all twins are born preterm. Triplets and more are almost always born preterm.

Types of Multiple Pregnancy

The ultrasound scan will show whether your babies share a placenta and/or amniotic sac. This
will affect your care during pregnancy and birth.

Types of twins

o Dichorionic diamniotic twins (DCDA) – each baby has a separate placenta and
amniotic sac.

o Monochorionic diamniotic twins (MCDA) – the babies share a placenta but have
separate amniotic sacs.

o Monochorionic monoamniotic twins (MCMA) – the babies share a placenta and

amniotic sac.

Types of triplets

o Trichorionic triamniotic triplets – each baby has a separate placenta and amniotic sac.
 o Dichorionic triamniotic triplets – 1 baby has a separate placenta and 2 of the babies
share a placenta. All 3 babies have separate amniotic sacs.

o Dichorionic diamniotic triplets – 1 baby has a separate placenta and amniotic sac, and
2 of the babies share a placenta and amniotic sac.

INTRAUTERINE DEATH

Intrauterine death, also known as stillbirth, refers to the death of a fetus inside the womb
before delivery. It is typically diagnosed when a baby dies after 20 weeks of gestation.
Causes can vary and may include genetic factors, placental problems, infections, or maternal
health issues.

The diagnosis is made by ultrasound scan following the clinical findings, which can include
vaginal bleeding, absent fetal heart sounds on electronic auscultation, a failure to feel fetal
movements or a uterus that is significantly smaller than the expected size (152). IUFD may
be managed expectantly, or treated surgically (D&E) or medically.

Types of Intrauterine Death

There are different types of stillbirths, broadly classified based on the timing and underlying
causes:

 Early Stillbirth: Occurs before 28 weeks of pregnancy.

 Late Stillbirth: Occurs after 28 weeks of pregnancy.

The causes can be further categorized into:

 Fetal Factors: Genetic abnormalities, structural malformations.

 Placental Factors: Issues with blood flow, placental abruption.

 Maternal Factors: Chronic health conditions, infections.

Management

Treatment options for stillbirth depend on various factors and individual circumstances. In
many cases, the focus is on delivering the baby, and the methods may include:

Labor Induction: Stimulating contractions to deliver the fetus.

Cesarean Section: Surgical delivery if necessary or preferred.

Medical Management: Medications to aid in the induction of labor.

After delivery, emotional and psychological support is crucial for parents. Autopsy and other
diagnostic tests may be performed to understand the cause of stillbirth, which can help in
preventing future occurrences. Grieving support and counseling are often recommended to
help cope with the loss. Each case is unique, and healthcare providers tailor their approach
based on the specific situation and the needs of the parents.

PREGNANCY INDUCED HYPERTENSION

Pregnancy-induced hypertension (PIH) is a form of high blood pressure in pregnancy. It

occurs in about 7 to 10 percent of all pregnancies. Another type of high blood pressure is
chronic hypertension - high blood pressure that is present before pregnancy begins.

Pregnancy-induced hypertension is also called toxemia or preeclampsia. It occurs most often

in young women with a first pregnancy. It is more common in twin pregnancies, and in
women who had PIH in a previous pregnancy.

Usually, there are three primary characteristics of this condition, including the following:

 high blood pressure (a blood pressure reading higher than 140/90 mm Hg or a

significant increase in one or both pressures)

 protein in the urine

 edema (swelling)

CAUSES OF PREGNANCY-INDUCED HYPERTENSION

The cause of PIH is unknown. Some conditions may increase the risk of developing PIH,
including the following:

o pre-existing hypertension (high blood pressure)

o kidney disease

o diabetes

o PIH with a previous pregnancy

o mother's age younger than 20 or older than 40

o multiple fetuses (twins, triplets)

Symptoms Of Pregnancy-Induced Hypertension

 The following are the most common symptoms of high blood pressure in pregnancy.
However, each woman may experience symptoms differently. Symptoms may include:

 increased blood pressure

 protein in the urine

 edema (swelling)

 sudden weight gain

 visual changes such as blurred or double vision

 nausea, vomiting

 right-sided upper abdominal pain or pain around the stomach

 urinating small amounts

 changes in liver or kidney function tests

How is pregnancy-induced hypertension diagnosed?

Diagnosis is often based on the increase in blood pressure levels, but other symptoms may
help establish PIH as the diagnosis. Tests for pregnancy-induced hypertension may include
the following:

 blood pressure measurement

 urine testing

 assessment of edema

 frequent weight measurements

 eye examination to check for retinal changes

 liver and kidney function tests

 blood clotting tests

Treatment for pregnancy-induced hypertension

The goal of treatment is to prevent the condition from becoming worse and to prevent it from
causing other complications. Treatment for pregnancy-induced hypertension (PIH) may
include:

o bedrest (either at home or in the hospital may be recommended).

o hospitalization (as specialized personnel and equipment may be necessary).

o magnesium sulfate (or other antihypertensive medications for PIH).

o fetal monitoring (to check the health of the fetus when the mother has PIH) may include:

o fetal movement counting - keeping track of fetal kicks and movements. A change in the
number or frequency may mean the fetus is under stress.

o nonstress testing - a test that measures the fetal heart rate in response to the fetus' movements.

o biophysical profile - a test that combines nonstress test with ultrasound to observe the fetus.

o Doppler flow studies - type of ultrasound that uses sound waves to measure the flow of blood
through a blood vessel.

o continued laboratory testing of urine and blood (for changes that may signal worsening of
PIH).

o medications, called corticosteroids, that may help mature the lungs of the fetus (lung
immaturity is a major problem of premature babies).

o delivery of the baby (if treatments do not control PIH or if the fetus or mother is in danger).
Cesarean delivery may be recommended, in some cases.

Prevention of pregnancy-induced hypertension:

Early identification of women at risk for pregnancy-induced hypertension may help prevent
some complications of the disease. Education about the warning symptoms is also important
because early recognition may help women receive treatment and prevent worsening of the
disease.

HYDRAMNIOS

Hydramnios is a condition in which there is too much amniotic fluid around the fetus. It
occurs in about 1 percent of all pregnancies. It is also called polyhydramnios.

CAUSES OF HYDRAMNIOS

There are several causes of hydramnios. Generally, either too much fluid is being produced or
there is a problem with the fluid being taken up, or both. Factors that are associated with
hydramnios include the following:

 Maternal factors:

o Diabetes
 Fetal factors:

o Gastrointestinal abnormalities that block the passage of fluid

o Abnormal swallowing due to problems with the central nervous system or

chromosomal abnormalities

o Twin-to-twin transfusion syndrome

o Heart failure

o Congenital infection (acquired in pregnancy)

Symptoms of hydramnios

The following are the most common symptoms of hydramnios. However, each woman may
experience symptoms differently. Symptoms may include:

 Rapid growth of uterus

 Discomfort in the abdomen

 Uterine contractions

 The symptoms of hydramnios may resemble other medical conditions. Always

consult your doctor for a diagnosis.

Treatment for hydramnios

Treatment for hydramnios may include:

 Closely monitoring the amount of amniotic fluid and frequent follow-up visits with
the physician

 Medication (to decrease fetal urine production)

 Amnioreduction--amniocentesis (inserting a needle through the uterus and into the

amniotic sac) to remove some of the amniotic fluid; this procedure may need to be
repeated.

 Delivery (if complications endanger the well-being of the fetus or mother, then an
early delivery may be necessary)

The goal of treatment is to relieve the mother's discomfort and continue the pregnancy.

HYPEREMESIS GRAVIDARUM
Hyperemesis gravidarum is the most severe form of nausea and vomiting in pregnancy. It is
characterized by persistent nausea and vomiting not related to other causes that is associated
with a measure of acute starvation, such as ketosis and weight loss (>5% of prepregnancy
weight). This condition may cause volume depletion, electrolytes and acid-base imbalances,
nutritional deficiencies, and even death. Severe hyperemesis requiring hospital admission
occurs in 0.3-3% of pregnancies.

Signs and symptoms

The defining symptoms of hyperemesis gravidarum are gastrointestinal in nature and include
nausea and vomiting. Other common symptoms include ptyalism (excessive salivation),
fatigue, weakness, and dizziness.

o Patients may also experience the following:

o Sleep disturbance

o Hyperolfaction

o Dysgeusia

o Decreased gustatory discernment

o Depression

o Anxiety

o Irritability

o Mood changes

o Decreased concentration.

complications of hyperemesis gravidarum

Lack of fluid and nutrients (malnourishment) cause the most complications related to HG.
When you’re vomiting so frequently, it’s hard for your body to get the vitamins and nutrients
it needs. This could lead to complications like preterm birth or low birth weight. You may
also have bleeding in your throat or other side effects from excessive vomiting.

How Is Hyperemesis Gravidarum Diagnosed?

Your doctor will perform a physical exam and order the following lab tests to assess signs of
dehydration.

 A complete blood count

  A serum electrolyte test (blood test)

 Ketones urine test (when the body isn’t getting enough nutrients, it begins to break
down fat, which leads to an increase in waste products known as ketones).

 An ultrasound can confirm if you are carrying twins or multiples and can diagnose a
molar pregnancy

Treatment and Medication Options for Hyperemesis Gravidarum

If you have severe symptoms of hyperemesis gravidarum, you may need to be hospitalized.
Hyperemesis gravidarum is the second leading cause of hospitalization in early pregnancy.

For less severe cases, you may be able to seek treatment at home or at a doctor’s office.

While the course of treatment for hyperemesis gravidarum varies from person to person, your
doctor may recommend one or more of the following:

 Vitamin B6

 Small, frequent meals that include dry, bland foods such as crackers

 Intravenous fluids to help with dehydration

 For severe cases, parenteral nutrition, in which an intravenous (IV) solution of

vitamins and nutrients is given as a substitute for food

 Acupuncture and acupressure

 Ginger, taken in tea or through a capsule.

URINARY TRACT INFECTION (UTI)

A urinary tract infection (UTI) is an infection in any part of the urinary system. The urinary
system includes the kidneys, ureters, bladder and urethra. Most infections involve the lower
urinary tract — the bladder and the urethra.

Women are at greater risk of developing a UTI than are men. If an infection is limited to the
bladder, it can be painful and annoying. But serious health problems can result if a UTI
spreads to the kidneys.

Symptoms

UTIs don't always cause symptoms. When they do, they may include:
  A strong urge to urinate that doesn't go away

 A burning feeling when urinating

 Urinating often, and passing small amounts of urine

 Urine that looks cloudy

 Urine that appears red, bright pink or cola-colored — signs of blood in the urine

 Strong-smelling urine

 Pelvic pain, in women — especially in the center of the pelvis and around the area of
the pubic bone

Causes

UTIs typically occur when bacteria enter the urinary tract through the urethra and begin to
spread in the bladder. The urinary system is designed to keep out bacteria. But the defenses
sometimes fail. When that happens, bacteria may take hold and grow into a full-blown
infection in the urinary tract.

Treatment

Antibiotics usually are the first treatment for urinary tract infections. Your health and the type
of bacteria found in your urine determine which medicine is used and how long you need to
take it.

Simple infection

Medicines commonly used for simple UTIs include:

 Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS)

 Fosfomycin (Monurol)

 Nitrofurantoin (Macrodantin, Macrobid, Furadantin)

 Cephalexin

 Ceftriaxone

Prevention

You can help prevent UTIs by doing the following:

  Urinate after sexual activity.

 Stay well hydrated.

 Take showers instead of baths.

 Minimize douching, sprays, or powders in the genital area.

 Teach girls when potty training to wipe front to back.

PSYCHOSIS IN PREGNANCY

Psychosis refers to a severe mental condition where an individual experiences a loss of

contact with reality, often involving hallucinations, delusions, and impaired insight.

While relatively rare, psychosis can occur during pregnancy, affecting a small percentage of
pregnant individuals.

Types of Psychosis in Pregnancy:

Perinatal Mood Disorders: Mood disorders like depression and bipolar disorder can
contribute to psychosis during pregnancy.

Individuals with pre-existing mood disorders may be at a higher risk.

Postpartum Psychosis: Occurs in the postpartum period, typically within the first few weeks
after childbirth.

Symptoms may include hallucinations, extreme mood swings, and confusion.

Risk Factors:

 Biological factors: Hormonal changes during pregnancy.

 Psychological factors: History of mental health issues, especially mood disorders.

 Social factors: Lack of support, high stress levels, and significant life events.

Clinical Presentation:

 Symptoms may include hallucinations (seeing or hearing things that aren't there), delusions
(false beliefs), disorganized thinking, and impaired judgment.

 Distinguishing between typical perinatal stress and signs of psychosis is crucial.

Screening and Diagnosis

 Routine mental health screenings during prenatal care.

  Diagnosis involves a thorough assessment of symptoms and may require input from
mental health professionals.

Treatment Approaches:

1. Pharmacological Interventions:

 Medications may be considered, with careful evaluation of risks and benefits.

 Close monitoring for potential effects on the fetus.

2. Psychotherapeutic Approaches:

 Cognitive-behavioral therapy and supportive counseling.

 Inclusion of family members in the therapeutic process.

Preventive Measures

 Early identification and intervention for individuals at risk.

 Educational programs to reduce stigma and increase awareness of mental health

during pregnancy.

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