MALPOSITION &

MALPRESENTATION
By
Ahmad Makhlouf
 Contents

 Breech Presentation

 Transverse OR Shoulder Presentation

 Complex Presentation

 Umbilical Cord presentation & prolapse

 SCHEME FOR
MALPRESENTATION
 DEFINITION

 INCIDENCE

 POSITION

 ETIOLOGY

 MECHANISM OF LABOR
 DIAGNOSIS & INVESTIGATIONS
 MANAGEMENT DURING PREGNANCY, LABOR
 COMPLICATIONS
COMPLICATIONS
 MATERNAL • FETAL
1) PROM 1) Asphyxia
2) Cord prolapse 2) Operative birth injuries
3) Prolonged labor 3) Intracranial hemorrhage
4) Obstructed labor
5) Uterine inertia
6) PPH
7) Perineal lacerations
8) Puerperal sepsis
Breech Presentation
Breech presentation
 Definition:
It is a malpresentation in which the
presenting part is breech, the denominator is
the sacrum and the head is extended or
flexed.

 Incidence: (3 % at term, 15% at 28 w)

Incidence
 Incidence of breech presentation decreases with
gestation as spontaneous version happens.
 20% at 28 weeks of gestation
 16% at 32 weeks
 3-4% at term

 Hence, breech is more common

in preterm labours.
Breech presentation
 Types:
1. Complete breech: hips & knees are flexed – both feets are present
beside the buttocks (common in multipara)
2. Frank breech: hips flexed, knees extended – both feet are in front of the
head (common in primigravida)
3. Knee presentation: hips partialy extended, knees flexed
4. Footling presentation: hips& knees are extended – one or both feet
form the presenting part, most commonly predisposed for cord
prolapse.
The most common, the most safe type: FRANK

Complete
breech(left Frank breech
sacroposterior)
Three types of breech
Frank or extended Complete or flexed Footling breech:
breech: 65 to 70% breech: 30% 10%

Legs are flexed at the

Hips and knees are
hips and extended at One or both feet or
flexed.
the knees. knees present below
Presenting part:
Presenting part: the fetal buttocks.
Buttocks and feet
Buttocks
Breech presentation
Positions :
 (8) positions (LSA, RSA, RSP, LSP, RST, LST).

 Sacroanterior positions are more common than

sacroposterior positions because the concavity of the

front of the fetus fits into the convexity of maternal

lumbar spine
 Breech presentation
 Etiology: (fetal causes)
1. Prematurity (50%) the most common cause due to:

- relative excess AF allow free fetal movement

- the head is relatively larger than breech

2. Extension of legs prevents spontaneous version

3. IUFD: no fetal movement for version

4. Hydrocephalus: the large head occupies the fundus

5. Multiple pregnancy
 Breech presentation
 Etiology: (maternal causes)
• Polyhydramnios allow free fetal movement
• Oligohydramnios interfere with spontaneous version
• Septate, bicornuate uterus decrease the capacity of the fundus
• Fundal myoma decrease the capacity of the fundus
• Multiparity due to laxity of abdominal & uterine walls allow free fetal
movement
• Idiopathic
• Contracted pelvis doesn’t lead to breech
 Risk factors for persistent
breech presentation
Fetal conditions
Maternal conditions
• Multiparity • Preterm delivery
• Congenital uterine anomalies • Polyhydramnios
• Uterine fibroids • Oligohydramnios
• Previous breech presentation • Fetal macrosomia
• Placenta previa or cornual placenta • Multiple pregnancy
• Cephalo-pelvic disproportion • Fetal anomalies
Breech presentation
 Diagnosis: (during pregnancy)

1. Symptoms: hard tender mass in the upper abdomen, dyspepsia

2. Inspection:

- Fetal movements on both sides of middle line in SP positions

- Transverse groove above the
umbilicus ( neck) in SA positions
Breech presentation
 Diagnosis: (during pregnancy)
Palpation:
COMPLETE BREECH FRANK BREECH
FL = Amenorrhea < Amenorrhea due to
early engagement
FG Head easily felt Head less ballotable,
small knobs beside it
UG Back on one side,
limbs on other side
Extended limbs simulate
back
PG Breech: large, not
engaged
Breech: small regular
firm
FHS Heard at or above
umbilicus
Heard below umbilicus
due to early
engagement
Breech presentation
 Diagnosis: (during labor)
1. Abdominal examination: ( as before)
2. Vaginal examination: (after rupture of membrane)
 The 3 bony landmarks of breech (2 ischial tuberosities and tip of
the sacrum).
 The 2 ischial tuberosities are in the same line with the anal orifice.
 The direction of the sacrum denote the position.
 Passage of thick meconium
 The feet are felt beside the buttocks if complete breech.
DD of breech presentation
During labor:
breech / shoulder. The shoulder is a part of
meeting of three bony ridges; the humerus, the
clavicle and the spine of the scapula. The breech
has the hole of the anus. Passing the finger up
behind this hole will allow identification of the
knobs of the spines of the sacral vertebrae.
breech /face. But in the face the opening in the
face, the mouth has the alveolar margins around.
 Mechanism of breech delivery
Delivary of the buttock
Descent.
Engagement by the bitrochanteric diameter (10cm)
into one of the oblique diameter of the pelvis 12 cm.
Internal rotation: The anterior buttock meets the
pelvic floor firstly as a result of contraction of the
underlying levator ani muscle & rotates anteriorly 1/8
of a circle to bring the BTD in the anteroposterior
diameter of the pelvic outlet.
With further descent the anterior buttock appears
below SP.
 By lateral flexion of the spine, the

posterior buttock is delivered at

first followed by straightening of

the spine to deliver anterior

buttock.

 External rotation occurs so that the

sacrum become anteriorly.

Delivery of shoulders
 The biacromial diameter (12) descends in the same oblique diameter
as breech.
 The anterior shoulder meets the pelvic floor firstly, rotates forward 1/8
of a circle.
 The anterior shoulder appears below SP.
 The posterior shoulder is delivered by lateral flexion of the spine
followed by the anterior shoulder.
Delivery of aftercoming head
 The head engages by is (occipto-frontal 11.5
cm) into the opposite oblique diameter of the
pelvis.
 The occiput meets the pelvic floor firstly,
rotates forward 1/8 of a circle in SA positions
and 3/8 of a circle in SP positions.
 With further descent the sub occipital region
appears below SP and the head is delivered by
flexion.
 So the head delivered by the movement of Flexion in:
- Direct occipto – posterior (Face to Pubis).
- Face (Mento – Anterior).
- The after-coming head of the breech.

o The head delivered by the movement of Extension in:

- Normal labour only (Occipto – Anterior).
Breech presentation
 Management:
1. During pregnancy: trial of ECV
2. During labor: Types of Breech delivery
Case
A 30 year old, para one woman at 36 weeks
gestation attends antenatal clinic appointment
after a scan confirming a frank breech
presentation with normal liquor.
She had a previous normal vaginal delivery
and is otherwise low risk.

How would you manage her care?

Management of Breech at term
ECV declined/unsuccessful/
persistent breech at term
 Vaginal breech delivery Vs
Caesarean section
Consider woman’s
wishes

Consider all of the

Consider current
favourable factors for
evidence & guidelines
vaginal breech delivery

Document the discussion

and plan
Favourable factors for vaginal
breech delivery
Appropriate case
selection
Skilled practitioners
Healthy, normally
grown fetus in Adherence to strict
frank / complete protocols
breech with flexed
head Team work and
effective
communication
Successful vaginal
A
breech delivery with committed
no adverse outcomes mother
Intrapartum management of
breech
Intrapartum management of
breech
 Second stage management
• Delay active pushing until the breech
has descended to the pelvic floor.

• Episiotomy should be performed

when indicated to facilitate delivery.

• Avoid handling the breech or the

umbilical cord.

• Breech extraction should not be

used routinely, as it causes extension
of the arms and head.
Post delivery
 Cord bloods for blood gases

 Accurate documentation

 Debrief parents and staff

Types of breech delivery

1. CS delivery

2. Spontaneous breech delivery

3. Assisted breech delivery

4. Breech extraction
1- CS delivery when?
Absolute Indications of CS in Breech presentation:
1- Breech with primigravida
2- Breech with Contracted pelvis
2- Breech with Preterm delivery <2000 g
3- Breech with Fetal size > 3800 g.
4- Breech with Hyperextended head.
5- Footling breech

6- Breech with Prolapsed pulsating cord in first stage.

7- Twin first breech

8- Breech with previous CS or any scarred uterus.

9-Breech with hydrocephalic head

10- Any associated obstetric abnormality as palcenta previa.

Elective CS operation is done at 39 weeks.

2- Vaginal breech delivery
 Requirements:
it must be in hospital
- Proper choice of the case, no any indication of CS is present
-Every thing is ready for CS -Senior obstetrician in charge
-Oxygen -Warm towels
-Piper forceps -Catheter
-Anesthesia -episiotomy
-anesthesiologist , assistant & neonateologist.
 Types of vaginal delivery:
1-Spontaneous breech delivery

 This is the hand - off procedure, when no operative

interference is used.
 The fetus is born spontaneously by the natural forces.
 This is occur only in case of Multipara, adequate pelvis,
strong uterine contraction and small sized fetus
(premature).
 SHOULDN’T BE ALLOWED TO OCCUR
2-Breech extraction

The only indication is to deliver transverse lie second twin after

Internal podalic version.

3-Assisted breech delivery
 Applied for most cases.
 The fetus is born spontaneously up to the umbilicus then
interference occurs to assist the delivery of shoulders and
aftercoming head.

1. Once the breech appears at the vulva, a sterile pad is applied over
the buttocks &push it upwards during contractions to ensure full
cervical dilatation , increase head flexion and prevent arrest of
head .
Assisted breech delivery

2. When the perineum is maximally distended, generous episiotomy is

done followed by spontaneous delivery of the breech & trunk up to the
umbilicus.

3. The fetus is covered by warm towels to prevent premature stimulation

of respiration and holded by abdomino-pelvic grip

4. Pull down a loop of cord.

5. Always maintain the back anteriorly towards the mother abdomen to

ensure good flexion of head.
Assisted breech delivery

6. When the anterior scapula appears below SP, the

arms are delivered followed by spontaneous delivery
of the shoulders.

7. Delivery of the aftercoming head.

The aftercoming head should be delivered within 3 – 5
minutes by one of the 3 methods:

1. Burns-Marshal method
2. Jaw flexion and shoulder traction (Mauriceau-
Smellie-Veit method).
3. Piper Forceps Delivery of the aftercoming
head
Burns –Marshall technique
1. The body of the fetus is left hanging down from the mother (but
supported to avoid slipping).
2. This leads to help engagement, increase flexion.
3. After the suboccipital region appears below SP ( to avoid fracture
dislocation of cervical spine) the head is delivered by lifting the
fetal body towards the mother abdomen (not more than 90).
4. The head is delivered by flexion.
Mauriceau- Smellie- Veit technique
Jaw Flexion – Shoulder Traction
1. The fetus is put on the left arm with
the index, middle fingers introduced
into its mouth to increase head
flexion.
2. The index, middle fingers of the
right arm are applied over the
shoulders from behind.
3. Traction is applied downwards and
backwards until the suboccipital
region appears below SP.
4. Then the fetus is moved upward
towards the mother abdomen to
deliver the head in flexion.
 Piper forceps delivery
1. The forceps is applied from the
abdominal aspect of the fetus.
2. Traction is applied downward and
backward till the suboccipital region
appears below SP.
3. Then elevated upward to deliver the
head in flexion.
4. Aesthesia is necessary for forceps
application.
5. Advantages: promotes head flexion,
prevent traction on the neck, protects
the head from compression –
decompression, intracranial hge.
 Complications of breech delivery

A- Maternal : as scheme.
B - Fetal mortality
1- Intracranial hemorrhage: (the commonest cause of death (50%)
1.Rapid compression-decompression as there is no sufficient time for

moulding to occur.

2.Excessive suprapubic pressure

3.Fetal asphyxia in preterrn leads to intraventricular hemorrhage

Fetal mortality
 How to avoid Intracranial hemorrhage:
1. Forceps to the aftercoming head.
2. Slow delivery of the head with generous episiotomy.
3. Vitamin K to the mother, fetus.
4. Avoid rough suprapubic pressure.
5. CS if breech , preterm.
Fetal mortality

2- Fracture dislocation of cervical spine: (the 2rd cause

of death (30%)

3- Intrapartum asphyxia: (the 3rd cause of death (15%)

4- Rupture of abdominal organ as spleen, liver: (the 4th

cause of death)

5- Fracture base of skull: (1%)

 Fetal morbidity
1. Depressed skull fractures from forceps
2. Facial nerve palsy
3. Dislocation or fracture mandible
4. Sternomastoid hematoma
5. Fracture clavicle, humerus, dislocation of shoulder
6. Fracture rips
7. Fracture femur, dislocation of hip
8. Dislocation of knee or ankle
9. Complications of prematurity
10. Long term: cerebral palsy, epilepsy, MR
EXTERNAL CEPHALIC VERSION
DEFINITION:

Changing the lie of the fetus inside the uterus by external

manipulations so the head become the presenting part

INDICATIONS:
 Breech diagnosed at 36 – 38 weeks.
 Transverse lie from 36 – 38 weeks.
EXTERNAL CEPHALIC VERSION

CONTRAINDICATIONS:
 Elderly PGDA
 Contracted pelvis
 Antepartum hemorrhage
 Hypertensive disorders
 Multiple pregnancy
 Uterine scar or anomalies
 Poly or oligohydramnios
 PROM
 Hydrocephalus, macrosomic baby
EXTERNAL CEPHALIC VERSION

TECHNIQUE:
Before 1. Abdominal US to confirm diagnosis
ECV 2. No anesthesia
3. Tocolytic as ritodrine can be given IV drip to
relax the uterus
4. Empty bladder, rectum
EXTERNAL CEPHALIC VERSION

TECHNIQUE:
ECV Stop manipulations immediately if there is:
•Pain
•FHR changes
•Vaginal bleeding occurs
EXTERNAL CEPHALIC VERSION

TECHNIQUE:
After 1. FHS is heared again, if there is fetal distress
ECV for more than 5 minutes, the fetus is returned
back to its position as the cord may be coiled
2. Give anti –D if RH negative
EXTERNAL CEPHALIC VERSION

COMPLICATIONS:
 PROM
 Placental separation
 Preterm labor
 Cord prolapse, true knots, coiling around fetus
 Fetal shock, distress, death
 Rupture uterus
 Rh isoimmunization
 Amniotic fluid embolism
 Failure or recurrence
Shoulder presentation
Shoulder presentation
 Definition:

It is a malpresentation in which the presenting

part is shoulder, the denominator is the scapula
and the longitudinal axis of the fetus crosses that
of the mother.

 Incidence: (1 : 200 deliveries)

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)
Shoulder presentation
o Positions: (4) positions
 Left scapuloanterior: back anterior, head left
 Right scapuloanterior: anterior , right
 Left scapuloposterior: posterior , left
 Right scapulopoterior: posterior , right

 Scapuloanterior are more common than posterior

Dorso-anterior Dorso-posterior
Shoulder presentation
 Diagnosis: (during pregnancy)
1. Inspection: - Abdomen
is transversely oval

2. Palpation:
- FL < amenorrhea
- FG: empty
- - UG: head to one side, lower & breech on other side, higher
( because it is heavier)
- -1st PG: empty

3. Auscultation:
- FHS heared on the side of the umbilicus (head)
Shoulder presentation
 Diagnosis: (during labor)
1. Abdominal examination: ( as before)

2. Vaginal examination: the presenting part may be

 Shoulder: The bony landmarks are axilla (cavity) with meeting of 3
bones (acromion, clavicle, humerus).
 Elbow differentiate from the knee (pointed).
 Hand vs Foot (no heel, long curved fingers, easy thumb mobility).
 To diagnose which hand, try to shake the fetus as the RT hand of
the fetus can be shaked corrrectly by the RT hand of the
obstetrician and the LT hand by the LT one.
Management of shoulder
1. Single Tve lie
During pregnancy
 Trial of ECV
During labor: CS
2. Neglected shoulder presentation= management of
Obstructed Labour in details.
3. Tve lie in Twins:
First of twin: do CS
Second of twin: allow ECV after delivery of the first, if failed
do IPV and deliver by breech extraction.
Retained second twin: CS
NEGLECTED SHOULDER

 Definition:
It is a shoulder presentation, the patient allowed in labor
(neglected) for a long time , so the shoulder become impacted
with the full picture of obstructed labor, impendeing rupture uterus
and dead fetus
 C/P: Full picture of obstructed labour : refer to this lecture and
Farouk Haseeb book
Neglected Shoulder
NEGLECTED SHOULDER
 Management:
1- correction of general condition by proper IV rehydration and
correction of acidosis
2- Urgent CS regardless of the fetal state
3- A tocolytic may be administered to allow for uterine relaxation
during fetus extraction.
4- A vertical LUS will be performed
5- Guard againt PPH
6- Antibiotics to guard againt GBS infection
7- Examine the genital tract for lacerations after CS
Cord presentation
Cord presentation
 Definition:

It is presence of umbilical cord below the PP before rupture of

membranes

CORD PROLAPSE: presence of umbilical cord below the

PP (overt) or beside the PP (occult) after rupture of membranes,
More common with shoulder then footling, then complete breech.,
treated by Urgent CS
 Conditions in which vaginal
delivery is impossible
 Persistentoccipitoposterior (POP)
 Deep transverse arrest (DTA)
 Face (mentoposterior – mentotransverse)
 Brow presentation
 Footling breech
 Shoulder presentation
 Cord presentation & cord prolapse
Conditions in which vaginal
delivery is possible
 Directoccipitoposterior (face to pubis)
 Face (mentoanterior)
 Frank & complete breech
THANK YOU