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Malpresentation and Malposition

Antenatal

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Aeman Waqar
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35 views31 pages

Malpresentation and Malposition

Antenatal

Uploaded by

Aeman Waqar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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MALPRESENTATION & MALPOSITION

Mohammad Hasan, Samra Choudhry, Shawnze Ilyas, Usman Khan


DEFINITIONS
Presentation: part of fetus that presents first in the maternal pelvis

Malpresentation: a presentation that is not cephalic.

Position: relationship of denominator to maternal pelvis

Malposition: occipito-transverse or occipito-posterior positions


MALPRESENTATION TYPES
Breech

Transverse lie

Oblique lie
BREECH PRESENTATION
Extended (frank) breech

Flexed (complete) breech

Footling breech
BREECH PRESENTATION PREDISPOSING FACTORS

Maternal: Fetal/Placental:

● Fibroids ● Multiple gestation


● Congenital uterine abnormalities ● Prematurity
● Uterine surgery ● Placenta Previa
● Polyhydramnios
ANTENATAL MANAGEMENT OF BREECH PRESENTATION
If a breech presentation is clinically suspected at or after 36 weeks, it should be
confirmed by ultrasound.

The three management options available should be discussed with the woman:

● External cephalic version (ECV)


● Vaginal breech delivery
● Elective C-section

It is recommended that the best method of delivering a term breech baby is by planned
C-section.
EXTERNAL CEPHALIC VERSION
ECV is a relatively straightforward and safe
technique and has been shown to reduce the number
of C-sections due to breech presentations.

Success rates vary but in most units are around 50%.

The procedure is performed at or after 37 weeks’


gestation.
VAGINAL BREECH DELIVERY
Pre-requisites

● Presentation should either be extended (frank) or flexed (complete)


● No evidence of feto-pelvic disproportion with a pelvis clinically adequate and an
estimated fetal weight of <3500 g
● No evidence of hyperextension of fetal head, and fetal abnormalities that would
prevent a safe vaginal delivery (ie. severe hydrocephalus)
VAGINAL BREECH DELIVERY
Management of labour

● Monitor fetal wellbeing and progress of labour


● Epidural analgesia
● Fetal blood sampling from buttocks
● Experienced operator available
VAGINAL BREECH DELIVERY

Delivery of the buttocks

● Buttocks lie in the anterior-posterior diameter


● Once anterior buttock is delivered, an
episiotomy can be cut
VAGINAL BREECH DELIVERY

Delivery of the legs and lower body

● If legs are flexed, they delivery spontaneously


● If legs are extended, may need to be delivered
by Pinard’s manoeuvre
VAGINAL BREECH DELIVERY
Delivery of shoulders
● Once the shoulders rotate into the
anterior-posterior diameter, the spine or
scapula become visible
● A finger is placed above the shoulder to help
deliver the arm
● Once the posterior shoulder reaches the
pelvic floor, it rotates anteriorly as well
● Movements mimicking a “rocking boat”
● Lovset’s manoeuvre
VAGINAL BREECH DELIVERY
Delivery of the head

● Mauriceau-Smellie-Veit manoeuvre
● Baby lies on the obstetrician’s arm with
downward traction being levelled on the head via
a finger in the mouth and one on each maxilla
● Forceps may be needed
OTHER FETAL MALPRESENTATIONS

● Transverse lie and oblique lie


● Potential risk of cord prolapse
● Risk of prolapse of hand,
shoulder, or foot
● Caesarean section required
MATERNAL PELVIS BOUNDARIES
THE PELVIC INLET
Pelvic inlet or brim is bounded anteriorly by upper
border of symphysis pubis.

Laterally by upper margin of pubic bone,


iliopectineal line & ala of sacrum.

Posteriorly by the promontory of sacrum.

Angle of inlet is normally 60*.


THE MIDPELVIS
Also known as the midcavity, bounded anteriorly by the middle of
symphysis pubis.
Laterally by pubic bone, obturator fascia & the inner aspect of the
ischial bone & spine.
Posteriorly by the junction of 2nd & 3rd section of the sacrum.
Used for 2 important landmarks:
Assess the descent of the presenting part on vaginal
examination.
To provide local anaesthetic pudendal nerve.
THE PELVIC OUTLET
Bounded anteriorly by the lower margin of symphysis
pubis.

Laterally by the descending ramus of pubic bone, ischial


tuberosity & sacrotuberous ligament.

Posteriorly the last piece of sacrum.

Transverse is the widest diameter at inlet but at outlet it's


the AP diameter.
THE PELVIC SHAPE
The pelvic measurements are of average value & relate bony points.

The gynaecoid pelvis is the most favourable for labour and also the most common.

An android type pelvis said to predispose to failure of rotation & deep transverse arrest.
THE PELVIC SHAPE
Anthropoid shape encourages an occipito-posterior position.

A platypelloid pelvis associated with an increase risk of obstructed labour due to


failure of head to engage.
THE PELVIC FLOOR
Formed by the two levator ani muscles with their fascia, form a musculofascial gutter
during second stage of labour.

The configuration of the bony pelvis with gutter shaped pelvic floor muscle
encourages fetal head to flex and rotate.
THE PERINEUM
The pineal body is a condensation of the fibrous & muscular tissue lying between the
vagina & anus.

Receives attachments of posterior end of bulbo-cavernous muscle, medial end of the


superficial & deep transverse perineal muscle and anterior fibres of external anal
sphincter.

Perineum is taut & relatively resistant in nulliparous women.

Its stretchy and less resistant in multiparous women resulting in faster labour.
THE PERINEUM
FETAL SKULL
MALPOSITION
What is malposition?

● Malpositions are abnormal positions of the vertex of the fetal head relative to the
maternal pelvis. Occipito-Anterior is the best for a normal and spontaneous
vaginal delivery. Right OP and Left OP are also normal but may require more time
for delivery for fetal head to rotate.

These are the different kinds of malpositions?

● Occipito-Transverse
● Occipito-Posterior
Occipito-Posterior
This is the most common type of malposition.

The head engages normally initially but then


rotates posteriorly instead of anteriorly.

This results from a poorly flexed vertex.

It may be due to a flat sacrum or weak uterine


contractions, which in turn may not push the fetal
head into the pelvis with sufficient strength to
produce correct rotation.
OP Management
These deliveries usually result in a long labour, where
close fetal and maternal monitoring is required.

An epidural is usually recommended, and it is


necessary to give the mother fluids.

If the position is not ideal, a Cesarean section may be


required.
Occipito-Transverse
In this malposition the fetal head engages correctly but does not rotate fully and stays
in the transverse position
OT Management
There can be manual rotation of the
fetal head with Keillands forceps.
Most places prefer to do cesarean
sections and not the forceps.
Malpositions
EFFECT OF FETAL ATTITUDE ON THE PRESENTING DIAMETER

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