Delivery With Malpresentation

PREGNANCY AND
DELIVERY WITH
MALPRESENTATION and
MALPOSITION
dr. Muthiah Nurul Izzah
TERMS OF FETAL POSITION
Lie Position
Presentation Habituation
The location of the The location of a certain
long axis of the Lowest part of The position of
part of the fetus against
child to the long the fetus child parts one
axis of the mother against the others the abdominal wall or
birth canal
Fetal anatomic part proceeding first into and

through the pelvic inlet
Obstetric Interventions. P. Joep Dörr, HMC Haaglanden Medical Centre,New York : Cambridge. 2017
MALPRESENTATION
DEFINITION
Fetus is in a noncephalic or nonvertex presentation
Are associated with increased rates of

adverse maternal and perinatal events
Cunningham FG, Leveno KJ, Bloom SL, Dashe JS, Spong CY, Hoffman BL, et al. Williams Obstetrics, 26e. 2022.
RISK FACTORS
Amniotic fluid Fetal

Fetal size
volume anomalies
Maternal
Pelvic structure
habitus
MALPRESENTATION
Breech Shoulder Compound

Presentation Presentation Presentation
Face Brow
Presentation Presentation
BREECH PRESENTATION
EPIDEMIOLOGY
Approximately 3–4% of singleton births involve a breech presentation
Breech presentation is the most commonly

encountered fetal malpresentation
The incidence decreasing with advancing gestational

age
BREECH PRESENTATION
DEFINITION
A fetus with the feet or buttocks presenting in the pelvic

inlet and is the most common type of malpresentation
footling breech
FRANK COMPLETE INCOMPLETE

BREECH PRESENTATION
Frank Breech
• The fetus is in a pike position with the buttocks presenting and the hips
flexed, but knees extended
Complete Breech
• The fetus has both knees and hips flexed so the feet are near the
buttocks, but the buttocks are presenting
Incomplete Breech
• The fetus has either one or both knees flexed and one or both hips flexed
resulting in either the feet or the knee below the buttock
Footling Breech
• A type of incomplete breech wherein the fetus has one or both feet
presenting
BREECH PRESENTATION
DIAGNOSIS
• Leopold Examination
• Pelvic Examination
LEOPOLD
• First manuever : hard, round fetal head occupies the fundus
• Second manuever : hard, broad back to be on one side of the abdomen
• Third manuever : if not engaged, the softer breech is movable above the pelvic
inlet
• Fourth manuever : after engagement, the fourth maneuver shows the breech to
be beneath the symphysis
BREECH PRESENTATION
PELVIC EXAMINATION
• A frank breech : no feet are appreciated, but the fetal ischial
tuberosities, sacrum, and anus are usually palpable
• Complete breech : the feet alongside the buttocks
• Footling breech : one or both feet are inferior to the buttocks.
The fetal sacrum is palpated to establish position
BREECH PRESENTATION
Left Sacrum Anterior

• Fetus’s back is up and its sacrum occupies the
left upper (ventral) quadrant of the mother’s
pelvis.
Right Sacrum Anterior
Right or left sacrum posterior
Right or left sacrum transverse
BREECH PRESENTATION
Factors Favor Cesarean Section in
Breech :
DELIVERY ROUTE
• Vaginal Delivery
• Cesarean delivery
BREECH PRESENTATION
Zatuchni Andros Score
If ZA Score <4 predict poor outcome  Caesarean section

BREECH PRESENTATION
Vaginal Delivery
BREECH PRESENTATION
BREECH PRESENTATION
Vaginal Delivery Method
• The fetus is expelled entirely without any traction or manipulation other

Spontaneous than the support of the newborn
breech delivery
• The fetus is delivered spontaneously as far as the umbilicus, but the

remainder of the body is delivered by provider traction and assisted
Partial breech
extraction maneuvers, with or without maternal expulsive efforts
• The entire fetal body is extracted by the provider

Total breech
extraction
BREECH PRESENTATION
Partial Total Breech

Spontaneous
Extraction Extraction
Bracht Arms delivery

Classic
Muller
Lovset
Aftercoming
head
Mauriceau
De snoo
Cunningham FG, Leveno KJ, Bloom SL, Dashe JS, Spong CY, Hoffman BL, et al.
Williams Obstetrics, 26e. 2022. Forcep
BREECH PRESENTATION
Lovset
Mueller
BREECH PRESENTATION
De Snoo
Brach
Mauriceau
Forcep
BREECH PRESENTATION
PARTIAL FULL
SPONTANEOU
EXTRACTIO EXTRACTIO
S BRACHT N N
• Spontaneous delivery of • If the fetus is hypotonic, for example
baby Performed only when there are
because the mother is receiving indications to end labor or alleviate
• Arm, shoulder, and head medication or asphyxia, tipping of the
born in one move the second stage
fetal arm behind the neck can occur
• No Asphyxia  partial extraction
• Good tone • Bracht manuever is considered as
• Good mother condition failure
BREECH PRESENTATION
Reitter, Anke & Halliday, Alexandra & Walker, Shawn. (2020). Practical insight into upright breech birth from birth videos: A structured analysis. Birth. 47. 10.1111/birt.12480.
EXTERNAL CEPHALIC
VERSION (ECV)
Efficacy
• Reversion to breech occurs after
successful ECV, with between 3 and 7%
being reported for term ECV
• Rates of over 20% have been reported
for preterm ECV
EXTERNAL CEPHALIC
VERSION (ECV)
EXTERNAL CEPHALIC
VERSION (ECV)
Contraindications
• Multiple pregnancy
• Vaginal bleeding
• Low lying placenta
• Suspect IUGR
• Amniotic fluid abnormalities
• Uterine malformation
• Maternal cardiac disease
• Pregnancy induced hypertension
• Major fetal anomaly
EXTERNAL CEPHALIC
VERSION (ECV)
Complication
• Lihat slide the avi,,
FACE PRESENTATION OR
BROW PRESENTATION
DEFINITION
Malpresentation during labor when the presenting part is either the face
or, in the case of brow presentation, it is the area between the orbital
ridge and the anterior fontanelle.
FACE PRESENTATION
• An abnormal form of cephalic presentation
where the presenting part is mentum
• With this presentation, the neck is
hyperextended so that the occiput is in
contact with the fetal back
EPIDEMIOLOGY
Approximately 0.1 percent of
births
FACE PRESENTATION
DIAGNOSIS
• Abdominal Exam : The indentation will be palpated between
the occiput and back (fabre angle), the FHR is unilateral with a
small part of the fetus
• Vaginal examination: palpable face, mouth and jaw,
cheekbones, orbital bones, fetal head in maximal deflection
Vacuum extraction can’t be done in

Face Presentation
FACE PRESENTATION
Anterior chin position

• Complete dilation: deliver by spontaneous vaginal
delivery
• If the descent is prolonged, perform forceps extraction FHR monitoring during
• Uncomplete dilation : if there is no progress and labor is needed
decline  SC
Posterior chin position

• Complete dilation : SC
FACE PRESENTATION
FACE PRESENTATION
Internal rotation of the face brings the
chin underthe symphysis pubis
Mechanism of Labor
The neck traverse the posterior surface of
the symphysis pubis
The chin and mouth appear at the vulva,

and the undersurface of the chin presses
against the symphysis
Once the chin clears the symphysis, the

neck can flex
The nose, eyes, brow, and occiput appear

in succession over the anterior margin of
the perineum
FACE PRESENTATION
Mechanism of Labor
• Tambahin slide the avi
BROW PRESENTATION
• Diagnosed when that portion of the fetal
head between the orbital ridge and the
anterior fontanel presents at the pelvic inlet
EPIDEMIOLOGY
Range from 0.1 to 0.2 percent of
births
BROW PRESENTATION
DIAGNOSIS
• Abdominal Exam : Fetal head is more prominent above the
pelvis, the fetal heart is unilateral with a small part
• Vaginal examination: The occiput is higher than the scintilla,
the anterior fontanelle and orbit are palpable, the head enters the
pelvic inlet at the part between the orbital bone and the fontanel
area
BROW PRESENTATION
Management
• SC if the fetus is alive
Except when the fetal head is small or the pelvis is

unusually large, engagement of the fetal head and
subsequent delivery cannot take place
Engagement is impossible until marked molding

shortens the occipitomental diameter
FHR monitoring during labor is

needed
COMPOUND PRESENTATION
An extremity prolapses alongside the
presenting part, and both present
simultaneously in the pelvis
EPIDEMIOLOGY
An incidence of approximately 1 in
1000
COMPOUND PRESENTATION
Management
• Spontaneous labor can only occur if the fetus is very small/dead and
macerated
• Try repositioning: the mother is placed in a knee-chest position, push
the hands up outside of the symphysis pubis and hold until contraction
occurs so that the head descends into the pelvic cavity.
• Continue normal delivery management If head descends
• If the procedure fails / prolapse of the umbilical cord, perform SC
SHOULDER PRESENTATION
A malpresentation at childbirth where the baby is in a
transverse lie (its vertebral column is perpendicular to that
of the mother)
EPIDEMIOLOGY
0,3% of singleton births
Management
• Do the external version if the uterine and
amniotic surfaces are intact
• If the external version is contraindicated,
perform SC
• Monitor for umbilical cord prolapse
• Monitor Fetal Heart Rate
MALPOSITION
DEFINITION
Occiput posterior and occiput transverse positions
Accurate diagnosis of both conditions is

necessary for appropriate management
MALPOSITION
OCCIPUT POSTERIOR
DIAGNOSIS
• Abdominal Exam : Lowest part is flat, small part of the fetus is
palpated anteriorly and FHR is heard on the side (flank)
• Vaginal examination: The occiput towards the sacrum, the scintilla in
the anterior will be easily palpable when the head is deflected
OCCIPUT TRANSVERSE POSITION
DIAGNOSIS
• The occiput position of the fetus is still transverse to the
mother's pelvic cavity until the end of the 1st stage of labor
because it fails to rotate to the occiput anterior position  caused
by platypelloid or android pelvic
MALPOSITION
Specific Management
• If there are signs of obstructed labor / fetal distress
General Management  SC
• Spontaneous rotation occurs in • Amniotomy if membrane intact (+)
90% of cases • If the membranes are incomplete and there are no
• Observe if there are no signs of signs of obstruction  augmentation with
obstruction oxytocin
• Manual or forceps Rotation • If dilatation is complete and labor is not
progressing, check for signs of obstruction
• If there is no obstruction Manual rotation,
vacuum extraction/forceps
OCCIPUT TRANSVERSE/POSTERIOR
POSITION
Digital Rotation
• With head molding  suture override creates bony ridge
• Two fingers hooked against this ridge and forces directed
parallel to the skull can rotate the occiput toward the
anterior pelvis
• Done between contraction and held in place during maternal
pushing
OCCIPUT TRANSVERSE/POSTERIOR
POSITION
Manual Rotation
• With ROP The right palm, rotation clockwise
• With LOP  The left palm, rotation counterclockwise
• The operator’s fingers wrap to one side of the fetal face, and the thumb
extends along the other side
• Three action  flexed and destationing fetal head, pull the back of the fetus
externally toward midline
THANK YOU

Delivery With Malpresentation

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Delivery With Malpresentation

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PREGNANCY AND

Fetal anatomic part proceeding first into and

Fetus is in a noncephalic or nonvertex presentation

Are associated with increased rates of

Amniotic fluid Fetal

Breech Shoulder Compound

Approximately 3–4% of singleton births involve a breech presentation

Breech presentation is the most commonly

The incidence decreasing with advancing gestational

A fetus with the feet or buttocks presenting in the pelvic

FRANK COMPLETE INCOMPLETE

The fetal sacrum is palpated to establish position

Left Sacrum Anterior

Right or left sacrum posterior

Right or left sacrum transverse

If ZA Score <4 predict poor outcome  Caesarean section

• The fetus is expelled entirely without any traction or manipulation other

• The fetus is delivered spontaneously as far as the umbilicus, but the

• The entire fetal body is extracted by the provider

Partial Total Breech

Bracht Arms delivery

Vacuum extraction can’t be done in

Anterior chin position

Posterior chin position

The chin and mouth appear at the vulva,

Once the chin clears the symphysis, the

The nose, eyes, brow, and occiput appear

Except when the fetal head is small or the pelvis is

Engagement is impossible until marked molding

FHR monitoring during labor is

Occiput posterior and occiput transverse positions

Accurate diagnosis of both conditions is

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