1. Dr. Nadia Saddam AL.Assady
Mal presentation By
Dr. Nadia Saddam AL.Assady
C.A.B.O.G

2. Near term & during lobar, the fetus normally assumes a longitudinal lie & presents with cephalic pole to the maternal pelvis with the neck flexed & the vertex with the lowermost part of the uterus.
Definitions:
Lie: the relationship between the long axis of the fetus & the long axis of the uterus.
Presentation: that anatomical part of the fetus which presents itself first to the birth canal.

3. Denominator: an arbitrary point on the presenting part, chosen by convention, to describe the relationship of the presenting part to the birth canal.
Position: the relationship between the denominator & the birth canal for any given presentation.
Attitude: whether the presenting part is flexed or deflexed.
Station: the relationship between the lowest point of the presenting part & the ischial spines.

4. Mal presentation:
define as any presentation other than vertex, this includes face, brow & shoulder, as well as, compound presentation
etiology:
A-maternal factors:
1-high parity: increasing muscle laxity in the maternal anterior abdominal wall so fails to act as a brace to maintain
the longitudinal fetal lie is the most frequent associated factor. In addition, there is a commonly held view that the highly parous uterus has reduce myometrial tone, but this has not been proven.

5. 2-placenta previa: the mal presentation may be the only clinical feature leading to diagnosis of placenta previa.
3- pelvic tumors: ovarian cysts & low lying fibroids can obstruct the fetal head or breech entering the pelvis & may result in high head or breech & transverse or oblique lie.
4-uterine malformation: subseptate uterus, uterus bicornis & uterus didelphys may lead to mal presentation.
5-distended maternal urinary bladder: urinary retention with distended bladder can cause temporary change in fetal lie which resolve with voiding or bladder catheterization.

6. B-Fetal factors:
1-poly hydramnios: excessive volumes of liquor produced marked uterine distension enabling the fetus to move around & its most common pathological cause for unstable lie & mal presentation.
2-oligohydramnios: by restricting fetal movement can prevent the breech from undergo spontaneous version to cephalic.
3-multiple pregnancy: usually associated with mal presentation of one or both fetouses.

7. 4-fetal macrosomia: can produce mal presentation.
5-fetal abnormalities: hydrocephaly, tumor of fetal neck or sacrum, fetal abdominal distension like hydrops fetalis & fetal neuromuscular dysfunction including distended legs may cause mal presentation.

8. Face presentation:
The incidence is [1/500]. It is due to complete extension of the fetal head, in the majority of cases, the cause for extension is unknown may attributed to excessive tone of the extensor muscles of the fetal neck. The presenting diameter is the submento-bregmatic, which measure (9.5 cm) which is similar to the presenting diameter in vertex presentation.

10. Etiology:
1-fetal malformations: such as anencephaly, meningocele & thyroid goiters & tense extensor neck muscles prematurity, poly hydramnios, pelvic tumor, placenta previa multiple pregnancy, multi parous & malformation of uterus.

11. Clinical finding :
On abdominal examination between the anterior shoulder & the head prominence there is a characteristic deep depression in which no fetal part can be felt but in truth the diagnosis is made on vaginal examination, the landmarks include the mandible, mouth, nose, malar & orbital ridges. Care should be taken to avoid damaging the eyes. Historically, in obstructed lobar with edema, the differentiation between face & frank breech could be difficult, in modern obstetrics, U/S should resolve any doubt.

12. During labor, delay in the second stage is common
During labor, delay in the second stage is common. As long as the position is mento anterior, once the face is seen at the vulva, the head may born by flexion, there may be considerable perineal trauma, so generous episiotomy is advised. Mento posterior position is incompatible with vaginal delivery unless rotation occurs or
the fetus is small enough for the shoulder to enters the pelvis at the same time as the head. Following delivery the fetus face is very edematous & may be bruised. This usually persist for several days & may cause feeding difficulties.

13. Management:
1-U/S to exclude fetal or pelvic abnormalities that may preclude vaginal delivery.
2-if the diagnosis is made during the first stage of lobar so discussion with the mother about the risk of both vaginal & caesarean section. The risk of vaginal delivery include soft tissue trauma to fetal face, perineal damage include anal sphincter injury to mother, & 2nd stage emergency C/S.
3-by the time of diagnosis is made, considerable soft tissue trauma to the fetal face may already have occurred, which will not be prevented by abdominal delivery .

14. 4- furthermore around half the cases of mento posterior position will rotate in the 2nd stage to mento anterior so if good progress vaginal delivery can be expected.
5-if there is poor progress, the use of oxytocin is contaversial & C/S usually advised if there is no progress within 2 hours.

15. Brow presentation :
The incidence rate is (1/2000) of lobar, it is arise when there is less extreme extension of the fetal neck than that of face presentation, it can be considers a midway position between vertex & face the etiology is similar to that of face presentation with prematurity associated with (20%) of cases.
Although some cases arise as a result of extension associated with OP position.

17. Clinical feature:
1-abdominal findings typically include large high head as the large mento-vertical diameter (13cm) is less likely to engaged.
2-vaginally, the brow(bregma)is felt as a hard, rounded structure in the center of the cervix with the anterior fontanelle to one side& the orbital ridge & the nose opposite.
3-the diagnosis is often made late in lobar because the cervix needs to be considerably dilated to feel the landmarks, in the presence of large caput succedaneum it may be impossible to make the diagnosis with confidence.
4- vaginal delivery is possible if the vertex is small & the pelvis " capacious" with the face anterior.

18. Management:
1-U/S assessment to exclude fetal or pelvic abnormalities is essential unless already performed.
2- most cases will present late in lobar in the first stage with failure to progress, augmentation with oxytocin is considered although there is no evidence of it is efficacy in this situation, extreme caution is advised in multipara & grand-multipara due the risk of uterine rupture.
3-if the diagnosis is made early in first stage it wisdom to wait events as majority will either resolve to vertex or progress to face & manage accordingly, however, in all cases , if the head remain high & the brow presentation persist so C/S is required.

19. Unstable, transverse & oblique Lie:
Incidence & etiology: around (1/300), it is more common in multipara than nulliparous involve abnormalities of the uterus, pelvis or fetus. The effect of parity is likely to reflect increasing laxity in the abdominal wall musculature failing to orientate & hold the fetus in a longitudinal lie. There is no evidence to support the commonly held view regarding increasing laxity of the uterine tone.

21. Predisposing factors include: polyhydrominous which allows the fetus greater freedom of movement uterine septum is rarely associated with unstable lie but commonly with breech presentation placenta praevia discourage pelvic engagement of fetal pole tansient factors such as full urinary bladder fixed obstructions such as pelvic tumors ( including fibroids & ovarian cysts) & deformity or contracture of bony pelvis.

22. 6-fetal factors include multiple pregnancy, macrosomia, hydrocephaly, tumor of the neck or the sacrum, fetal abdominal distension or neuromuscular dysfunction ( abnormal posture & dyskinesia).
Clinical feature:
Inability to locate a fetal pole in the pelvis on either abdominal or vaginal examination whether in the antenatal period or during lobar.

23. Management:
1-U/S examination should be used to confirm the lie, exclude fetal anomaly & pelvic tumor & localize the placenta, however, it is not usually possible to diagnose congenital uterine anomalies using U/S during late pregnancy.
2-clinical examination after exclusion placenta previa is considered sufficient to exclude pelvic deformity or space occupying tumor so if reveal any indication for C/S should done at appropriate time.
3- owing to the risk of cord prolapse, all women with unstable lie should be instructed to attend for assessment if they begin to contract or suspect loss of liquor.

24. 4- management can be outpatient or inpatient , expectant or active , spontaneous version to longitudinal lie will occur in (80-85%) of women prior to lobar or membrane rupture. However , due to risk of cord prolapse where lobar occur prior to version inpatient management is suggested after 37 weeks gestation.
5- expectant inpatient management involves daily assessment & discharge home once the lie stabilized for 48 hours.

25. 6-active inpatient management involving ECV, either alone with discharge home if successful, or in conjunction with induction of lobar " stabilizing induction". A " stabilizing induction" require a favorable cervix & the used of oxytocin infusion & controlled amniotomy once cephalic presentation established, the risk of cord prolapse is explained to mother & the need for emergency C/S should this occur.
7-if the fetal lie is persist post term (41-42 weeks) elective C/S offered

26. 8-if the patient present in lobar or ruptured membrane the choice is emergency C/S & there is no place for internal podalic version except for the occasion for the second twin.
9-delivery at C/S may be complicated by both lack of liquor & inability to move the fetus into longitudinal lie so vertical uterine incision may be needed.

39. Thank you