Malpresentaton and

Breech presentation
 Definitions
• Position
• The relationship of a defined area on the presenting part
to the mother’s pelvis (Denominator)
• Presentation
• The part of the fetus occupying the lower segment
• The part of fetus felt on vaginal examination
 Normal Presentation
• Normal Presentation;
• Bony Pelvis
– Pelvic Brim
– Pelvic cavity
– Pelvic outlet
• Vertex
The area of the skull between the anterior and
posterior fontanelles, and the parietal eminence
Top of the skull
• Occiput
Back of the fetal head behind the posterior
fontanelle
• Sinciput
That part of the fetal head in front of the anterior
fontanelle.-forehead or brow
 Malpresentation

Breech
Face
Brow
Shoulder
Cord
Compound
 Consequences
• Presnting part, ill-fitting
• Uterine Contractions, poor
• Membranes, rupture early- cord prolapse
• Labour, difficult, long, obstructed
• Birth trauma
• Operative intervention
 Mother, Fetus and neonate

• Increased perinatal mortality and

morbidity
 Fetal malformation
 Intrauterine fetal death
 Cord proplase
 Birth trauma,
 Birth asphysixa
 Infection, fetus, neonate and mother
 Uterine rupture
 Thromboembolism in the mother
 For Optimal Result
• Early diagnosis,
• Planned delivery
• Experienced staff
• Well equipped hospital
• Cross match 2 unit
• Adequate hydration
• Monitor in Labour
• Pain relief
 Face Presentaion

• 1:300
• Full extension of the head
• Presenting part: Face
• Denominator: Omentum/Chin
• Diameter; Subomento bregmatic 9.5cm
• Presentation, Mento anterior– Vaginal delivery
Mento posterior- Ceasaeran section
 Causes
• Anenecephaly
• Prematurity
• Multifetal pregnancy
• Polyhydramnious
• Neck tumours
• Sternomastoid spasm
• Multiparty
 Diagnosis

• Abdominal
• Vaginal
 Brow Presentation
• 1:800, 1:2000 deliveries
• The area between the orbital ridge and the
anterior fontenalle
• Most unfavourable of all presentation
• Transient presentation;
Full flexion—Occiput
Full extension---Face
 Dignosis and management
• Delivery??
 Shoulder presentation
Causes
• Multiparty
• Prematurity
• Multiple pregnancy
• Polyhydrmanious congenital uterine
anomly
• Contacted pelvis
• Pelvic tumour, placenta previae
 Compound presentation
• Limb, limbs, umbilical cord alongside the
presenting part; cephalic or breech
 Umbilical cord presentation
• Umbilical cord, alongside or below the
presenting part , membranes intact.
• Cord prolapse, the memebranes have
ruptures
 Breech presentation
-Fetus presenting by the buttock/ feet/foot
Types
30% at 30 weeks, 3% of all deliveries at term
Flexed
Fetal buttock as well as fetal feet present to the pelvic inlet

Extended
The buttock alone present to the pelvic inlet (Frank)
 Fooling
one or both feet presenting
 Causes of breech presentation

• Prematurity
• Multiparity
• Multiple pregnancy
• Pelvic mass
• Placenta previae
• Fetal malformation
 Risks

• Increased perinatal morbidity and mortality

Due to;
Prematurity
Congenital abnormalities; hydrocephalus
Cord prolapse
Birth asphyxia
Birth trauma ; intra-cranial haemorrhage
 Diagnosis
• Abdominally,
Palpation:
Soft irregular presenting part
Firm, round, ballottable head in the uterine
fundus
 Management
• No action until 37-38 weeks of gestation
Reason???

Exclude fetal anomalies

Placenta previae
Multiple pregnancy
Offer external cephalic version (ECV)
Should not be attempted if there are risks
Risks???
Prerequisites??
Drawbacks of ECV
 Delivery
• Assisted Vaginal Breech delivery
• Elective Caesarean Section (CS)
• Emergency CS
• Selection for vaginal delivery
 Average fetal weight not more than 3.5kg
 Normal pregnancy
 No growth restriction
 Willing parents
 Experienced staff, Midwife, Obstet,
neonatologist, anesthetist
 Assisted vaginal breech delivery

• Close supervision
• Epidural analgesia
• Progress of labour
Second stage of labour, can be dangerous
Observe for delivery of the breech,
Hands off
o Help is needed if the arms are extended above the head
Lovset’s manoevour to deliver the shoulder
o Delivery of head, forceps or head traction jaw flexion
• Sutures
The term applied to the junction between the bones of the fetal skull, the
chief sutures are between the frontal bones( frontal) parietal bone(
sagittal), parietal and frontal (coronal), parietal and occiput
(Lmbdoid).

• Caput succedaneum
Oedema from obliterated venous return and lymphatic drainage in the
fetal scalp caused by pressure of the head against the rim of the
cervix or birth canal not limited by suture. Collection between
appenerouses and periostium.

• Cephalhaematoma
A collection of blood beneath the periostium of a skull bone. Limited by
sutures, appear after few hours of birth.
 Definitions related to fetus
• Bregma;
The large diamond shaped anterior fontanelle
• Fontanelles;
Space at the junction of three or skull bones, covered by a
membrane and skin.
Can be felt by running a finger through 360 degrees to feel
the sutures.
Anterior Fontenalle
Posterior Fontenalle
Small and triangular space in the fetal skull situated in the
posterior end of the sagittal sutures.
• Attitude of fetus
Relationship of fetal head and limbs to fetal trunk,
usually flexion

• Lie of the fetus

Relationship of the long axis of fetus to the long
axis of the uterus, usually longitudinal lie, (
Transverse, oblique). Usually to the long axis of
the mother.

• Position of the fetus

The relationship of a defined area on the
presenting part, called the denominator to the
mother’s pelvis
 Further readings
• www.patient.co.uk
 The following statements about
breech delivery are correct
1. Lovset’s manouver is employed to deliver
the head.
2. Breech extraction is less hazardous than
assisted beech delivery