MALPRESENTATION

Normal Lie
 Fetal lie refers to the relationship between the long axis
of the fetus with respect to the long axis of the mother.

Normal lie is Longitudinal (which may be either Cephalic or

Breech) .
Abnormal Lie
 Where the long axis of the fetus is not lying along the
long axis of the mother .

It can be
 TRANSVERSE
 OBLIQUE (Unstable)
Normal lie Abnormal lie
MAL POSITION :
 When the fetus is lying longitudinally and the vertex is
presenting, but it is not in the Occipitoanteror position.

IT can be ;
 Occipitotransverse (LOT, ROT)
 Occipitoposterior .
Mal presentation ;-
Mal presentation is a presentation that is not cephalic.

A fetus is lying longitudinally but presents in any manner other

than vertex.

Examples :
Breech Presentation.
Face Presentation
Brow Presentation.
Shoulder Presentation.
Compound Presentation
Cord Presentation.
MalPresentations :
Abnormal lie is not an abnormal
presentation.
Predisposing factors for mal presentation:
Maternal :
 Fibroids .
 Congenital uterine abnormalities .
 Uterine surgery .
o Fetal/Placental:
 Multiple gestation
 Prematurity
 Placenta Previa
 Fetal abnormality (eg; anencephaly)
 Fetal neuro muscular condition
 Oligohydramnios.
 Polyhydramnios.
METHODS OF DIAGNOSIS:
Three principal methods ;

Leopold Maneuvers or Abdominal Examination.

Vaginal Examination

Imaging
BREECH PRESENTATION :-
Most commonly encountered mal presentation.

It occurs in 3-4% of term pregnancies.

 Three types of breech Presentation;

 Commonest extended (frank breech).
 Less common flexed (complete breech.)
 Least common footling breech .
 Diagnosis :-
Ultrasound :
If a breech is clinically suspected at or after 36 weeks, this
should be confirmed by ultrasound.
This scan should document fetal biometry, AFI, placental
site and the position of fetal leg

Vaginal Examination:
• Buttocks are Felt .
• Orifice is felt (if finger is introduced in grove meconium
may be present) .
Management Options:-
External cephalic version (ECV) .

Vaginal breech delivery .

Elective caesarean section .

External Cephalic version :
ECV is a process by which a breech baby can be
turned from buttocks to head first.

It is a safe technique and has been shown to reduce the

number of caesarean sections due to breech
presentation .

Success rate is 50%.

 Pre requisites for ECV :-
Written informed consent.

 At or after 37 completed weeks .

 Ultrasound examination .

 CTG before and after the procedure.

 Tocolytic (terutaline 0.25mg s/c 15 min before) .

Full preparation for cesarean section .

Anti D Administration if a woman is rhesus negative.

Procedure :-

one hand elevates the breech and the other

provides pressure behind the fetal head, neck
and back
Contraindications to ECV :
Fetal abnormality (hydrocephalus) .
Placenta Previa.
 Oligohydramnios or Polyhyramnios.
History of APH.
Previous caesarean or myomectomy scar on the
uterus.
Multiple gestation.
Pre eclampisa or hypertension.
Plan to deliver by caesarean section anyway.
Risks OF ECV :-
Placental abruption.

Premature rupture of membranes.

Cord accident .

Fetal bradycardia.

Transaplacental haemorrhage.
If ECV fails or contraindicated , and caesarean
section is not indicated for other reasons , then
women should be counselled regarding elective
caesarean section and planned vaginal delivery.
Pre requisites for vaginal breech delivery
:-
The presentation should be either extended or flexed
breech.

No evidence of feto-pelvic disproportion.

Pelvis should be adequate .

Estimated fetal weight should be less than 3.5 kg.

No evidence of hyperextension of fetal head and fetal

abnormalities.
Technique :-
A vaginal breech delivery is hands off technique.
 STEPS:
1.Delivery of the buttocks.
2.Delivery of the legs and lower body.
3.Delivery of the shoulders.
4.Delivery of the head.
 Careful mnemonic
 C…….. Check Dilatation, presentation and cord
 A……… Await umbilicus ( Pinard Maneuver)
 R……… Rotate for arms ( Lovset’s Maneuver)
 E……….Enter for Mauriceau –Smellie-Veit Maneuver
 F……….Flex head
 U……….Up Back (Sacrum Anterior)
 L……….Lift baby to Mother.
Delivery of the buttocks.
Full dilatation and descent occurs naturally.

When buttocks become visible ,and begin to distend the

perineum , preparation of delivery are made.

The buttocks will lie in AP diameter.

When anterior buttock is delivered , the anus is seen over

the fourchette , episiotomy can be given .
Pinards manoeuvers, for delivery of legs .
If the legs are flexed , they will deliver spontaneously
If extended, they need to be delivered using
PINARDS MANEOUVERS.

This entails using a finger to flex the leg at the

knee and then extend at the hip, first anteriorly
then posteriorly.
Assisted delivery of extended legs. The fingers splint the
femur, slightly abduct the and then flex the hip and knee
The manner of grasping the
breech for rotation and traction
 Loveset Maneuver.
Its is the rotation of Truck of fetus to facilitate the
delivery of the ARMs.

Keeping the back up during delivery is important

because it allows fetal head to enter pelvis OA.
The posterior shoulder has been rotated to the
anterior position and can be delivered
The fetus is elevated slightly to facilitate descent of the posterior
shoulder below the sacral promontory and then rotated 180
Keeping the back uppermost the body is rotated 180 C to
allow delivery of the other arm
Delivery of head :

 1.Mauriceau- Smellie-Veit (MSVManuever.

 2.Piper Forceps for after coming head

The head is delivered using Muriceau smellie viet manoeuvers, the bay
lies on the obstetrician arm with downward traction being levelled on
the head via a finger in the mouth and one on each maxilla.
Forceps to the after coming head (a). During initial descent and
flexion of the head the fetal trunk is kept horizontal (b) As the
fetal chin is delivered the forceps and body are raised in unison
 Complications
Cord entanglement, compression or cord Prolapse , may lead to
asphyxia .

Entrapment of the arms or the head leading to trauma and

asphyxia .

Fracture or dislocation of limbs

Damage to intra abdominal organs .

Cervical spine dislocation or fracture and Brachial plexus injury .

Increased risk of CTG abnormalities.

 Face Presentation :
Occurs in about 1 in 500 labors .

It occurs due to complete extension of the fetal head, may be due to fetal
anomaly.

Presenting diameter is submento- bregmatic = 9.5cm.

It is diagnosed in labor by palpating nose, mouth and eyes on vaginal

examination.

Mento-anterior can be delivered vaginally.

Mento posterior cannot be delivered vaginally , as extension over the

perineum cannot occur.
 Brow presentation :
It is the least common presentation.

Occurs in 1 in 2000 labors.

It arises when there is less extreme extension of the fetal neck than that
with a face presentation.

The presenting diameter is mento-vertical 13.5cm.

It is diagnosed by palpating the anterior fontanelle, supraorbital ridges

and nose on vaginal examintion.

It is incompatible with a vaginal delivery delivered by caesarean section .

Shoulder presentation
It occurs 1 in 300 pregnancies.

It occurs as a result of oblique or transverse lie of the fetus.

Diagnosed by abdominal palpation, the abdomen appears

asymmetrical , the SFH may be less than expected .

Delivery is by caesarean section only .

Delay in making the diagnosis risk cord Prolapse and uterine

rupture.
Compound Presentation :=
Its incidence is 0.1%.

When a fetal extremity Prolapses alongside the

presenting part, and both enter the maternal pelvis at the
same time .
vertex-hand
breech-hand
vertex-arm-foot
Management :
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 Caesarean section.