MALPRESENTATION

&MALPOSITION
LECTURE OVERVIEW
 Abnormal lie, malpresentation and malposition
 Malpresentation and its management
 breech

 face

 brow

 shoulder

 compound
DEFINITIONS
 Abnormal lie
 where the long axis of the fetus is not

lying along the long axis of the mother

 LONGITUDINAL (MAY BE EITHER

CEPHALIC OR BREECH)
 TRANSVERSE

 OBLIQUE

 UNSTABLE
DEFINITIONS
 Malpresentation
 where the fetus is lying longitudinally, but

presents in any manner other than vertex

 BREECH

 FACE

 BROW

 SHOULDER

 COMPOUND

 CORD
DEFINITIONS
 Malposition
 where the fetus is lying longitudinally

and the vertex is presenting, but it is not

in the OA position
 OT (LOT, ROT)

 OP
DEFINITIONS
 Malpresentation
 where the fetus is lying longitudinally, but

presents in any manner other than vertex

 BREECH

 FACE

 BROW

 SHOULDER

 COMPOUND

 CORD
MANAGEMENT OF BREECH
PRESENTATION AT TERM
Management options

(1) external cephalic version

(2) elective caesarean section

(3) trial of vaginal delivery

EXTERNAL CEPHALIC VERSION

 CONTRAINDICTAIONS:
 3rd trimester bleeding
 uterine anomalies

 ROM, oligohydramnios

 need for CS for other reasons (placenta praevia,

contracted pelvis, hyperextended head)

 indicated vaginal delivery (fetal death, anomaly

best delivered as breech)

EXTERNAL CEPHALIC VERSION

 SUCCESS
 60-70%
 TECHNIQUE
 after 36W
 CTG prior

 attempt to perform forward somersault

 tocolytic

 CTG after (8% bradycardia; 5% fetomaternal

haemorrhage)
 anti D (if Rh negative)
ELECTIVE CAESAREAN
SECTION
 EFW <2500g; >3500g
 preterm breech
 hyperextended fetal head
 palcenta praevia
 concerns re. fetal well being, including oligohydramnios
 footling breech
 10% risk of cord prolapse
 ?complete breech
 5% risk of cord prolapse (c.f. 1% with frank breech)
 ?all PG breech
CRITERIA FOR VAGINAL
DELIVERY
 Frank or complete breech
 EFW 2500-3500g
 gestational age >36 weeks
 fetal head must be flexed
 maternal pelvis must be adequate
 judged clinically or by pelvimetry
 no other maternal or fetal indiaction for CS
 experienced obstetrician, anaesthetist and paediatrician
present at delivery
 FACE PRESENTATION
 Incidence: 0.2%
 Mechanics of presentation:
 Characterized by extreme extension of the fetal head so the face (rather

than the skull) presents to the birth canal

 Aetiology
 any factor that favours extension such as fetal goitre,
anencephaly
 high maternal parity

 At diagnosis:
 60% mentoanterior
 15% mentotransverse

 25% mentoposterior
BROW PRESENTATION
 Incidence: 1:1400
 Mechanics of presentation:
 head is extended such that attitude is halfway between
flexion (vertex) and hyperextension (face)
 usually transitional- when the head is in the process of

converting from a vertex to a face or vice versa

 presenting part is between the facial orbits and anterior

fontanelle
 supraoccipitomental diameter is presenting 13.5cm; cf

9.5cm for suboccipitobregmatic (vertex) or

submentobregmatic (face)
AETIOLOGY
 Fetal
 prematurity, multiple
 Liquor
 polyhydramnios
 Uterine
 anomaly
 Placenta
 praevia
 Pelvis
 contraction, tumour
 Parity
 high maternal parity (80% of cases occur in women who are para3
or more)
MANGEMENT
 Exclude cord prolapse
 occurs in up to 20% of cases
 Otherwise expectant
 mostly doesn’t interfere with normal delivery
 vertex-foot: try to gently reposition the lower

extremity
 if arm prolapses in vertex-hand, wait and see if

it moves as head descends; if it converts to

shoulder presentation, deliver by CS
SUMMARY
 Abnormal lie, malpresentation, malposition
 Incidence, mechanics, aetiology, diagnosis,
management of
 BREECH PRESENTATION

 FACE PRESENTATION

 BROW PRESENTATION

 SHOULDER PRESENTATION

 COMPOUND PRESENTATION