1. Fetal Malpresentation
Dr Maryam

2. At the onset of labor, assessment of the fetal presentation with respect to the maternal birth canal is critical to the route of delivery.
At term, the vast majority of fetuses present in the vertex presentation, where the fetal head is flexed so that the chin is in contact with the fetal thorax. The fetal spine typically lies along the longitudinal axis of the uterus.
Dr Maryam

3. Nonvertex presentations (including
breech, transverse lie, face, brow, and compound presentations)
occur in less than 4% of fetuses at term.
Dr Maryam

4. Malpresentation of the vertex presentation occurs if there is:
deflexion the fetal head leading to brow or
extension of the fetal head leading to face presentation
Dr Maryam

5. The Wellflexed head
Dr Maryam

6. Face presentation
Dr Maryam

7. face presentation
The fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis.
The presenting portion of the fetus is the fetal face between the orbital ridges and the chin.
The fetal chin (mentum) is the point designated for reference during an internal examination through the cervix.
Dr Maryam

8. Possible etiology of face presentation
Multiple gestations
Grand multiparity
Fetal malformations
Prematurity
Cephalopelvic disproportion (CPD)
Dr Maryam

9. Face presentation is diagnosed late in the first or second stage of labor by examination of a dilated cervix.
On digital examination, the distinctive facial features of the mouth and nose, the malar bones, and particularly the orbital ridges can be palpated.
This presentation can be confused with a breech presentation because the mouth may be confused with the anus and the malar bones or orbital ridges may be confused with the ischial tuberosities.
Dr Maryam

10. position
Like the occiput, the mentum can present in any position relative to the maternal pelvis.
For example:
if the mentum presents in the left anterior quadrant of the maternal pelvis, it is designated as left mentum anterior (LMA).
Dr Maryam

11. Dr Maryam

12. Dr Maryam

13. brow presentation
Dr Maryam

14. brow presentation
The fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis.
The presenting portion of the fetal head is between the orbital ridge and the anterior fontanel. The face and chin are not included.
Dr Maryam

15. Causes of a persistent brow presentation
generally similar to those causing a face presentation and include:
cephalopelvic disproportion (CPD) or pelvic contracture
increasing parity
prematurity
Dr Maryam

16. More than 50% of brow presentations will convert to vertex or face presentation and labor courses are managed accordingly when spontaneous conversion occurs.
Dr Maryam

17. Nursing management of face and brow presentation
Close observation of labor progression because cephalopelvic disproportion (CPD), dysfunctional labor, and prolonged labor are much more common.
Continuous electronic fetal heart rate monitoring is considered mandatory.
Dr Maryam

18. Labor management of face presentation
Fetuses with face presentation with anterior mentum position can be delivered vaginally
Cesarean delivery is performed for the usual obstetrical indications, including:
arrest of labor
nonreassuring fetal heart rate pattern
Other positions
Dr Maryam

19. Labor management of brow presentation
The persistent brow presentation has a poor prognosis for vaginal delivery unless the fetus is small or the maternal pelvis is large.
Expectant management is reasonable if labor is progressing well and the fetal well-being is assessed, as there can be spontaneous conversion to face or vertex presentation.
The persistent brow presentation necessitates cesarean section delivery.
Dr Maryam

20. BREECH PRESENTATION
Dr Maryam

21. BREECH PRESENTATION EARLY LABOUR
Ideally, every breech delivery should take place in a hospital with surgical capability.
Attempt external version if:
Breech presentation is present at or after 37 weeks (before 37 weeks, a successful version is more likely to spontaneously revert back to breech presentation)
Vaginal delivery is possible
Membranes are intact and amniotic fluid is adequate
There are no complications (e.g. fetal growth restriction, uterine bleeding, previous caesarean delivery, fetal abnormalities, twin pregnancy, hypertension, fetal death).
If external version is successful, proceed with normal childbirth.
If external version fails, proceed with vaginal breech delivery or caesarean section
Dr Maryam

22. Dr Maryam

23. VAGINAL BREECH DELIVERY
A vaginal breech delivery by a skilled health care provider is safe and feasible under the following conditions:
complete or frank breech
adequate clinical pelvimetry
fetus is not too large
no previous caesarean section for cephalopelvic disproportion (CPD)
flexed head.
Dr Maryam

24. Nursing intervention in breech presentation
Examine the woman regularly and record progress on a partograph.
Continuous FHR monitoring
If the membranes rupture, examine the woman immediately to exclude cord prolapse 
Dr Maryam

25. Assisted Breech Spontaneous delivery to the umbilicus
Gentle traction on cord may have effect opposite to that desired
Up to four minutes from delivery of the umbilicus to complete delivery associated with Apgar scores of > 7 at 5 minutes
If legs do not deliver spontaneously can be assisted by Pinard manoeuvre
Note: Trapped head
Duhrssen incisions 10 and 2 o’clock
Dr Maryam

26. Pinard manoeuvre
Dr Maryam

27. Placement of the fingers during traction
Dr Maryam

28. Delivery of the arms - Lövset manoeuvre
Dr Maryam

29. Mauriceau-Smellie-Viet manoeuvre
Dr Maryam

30. Forceps to the aftercoming head
Dr Maryam

31. Do not rupture the membranes if :
The cord prolapses and delivery is not imminent, deliver by caesarean section.
There are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute) or prolonged labor, deliver by caesarean section.
Dr Maryam

32. Meconium is common with breech labor and is not a sign of fetal distress if the fetal heart rate is normal.
Dr Maryam

33. CAESAREAN SECTION FOR BREECH PRESENTATION
A caesarean section is safer than vaginal breech delivery and recommended in cases of:
footling breech
small or malformed pelvis
very large fetus
previous caesarean section for cephalopelvic disproportion (CPD)
hyperextended or deflexed head.
Dr Maryam

34. Fetal complications of breech presentation include:
cord prolapse
birth trauma as a result of extended arm or head, incomplete dilatation of the cervix or cephalopelvic disproportion ( CPD )
asphyxia from cord prolapse, cord compression, placental detachment or arrested head
damage to abdominal organs
broken neck
Dr Maryam

35. TRANSVERSE LIE
Dr Maryam

36. TRANSVERSE LIE AND SHOULDER PRESENTATION
If the woman is in early labour and the membranes are intact, attempt external version:
If external version is successful, proceed with normal childbirth;
If external version fails or is not advisable, deliver by caesarean section .
Monitor for signs of cord prolapse. If the cord prolapses and delivery is not imminent, deliver by caesarean section.
Dr Maryam

37. Shoulder dystocia (Stuck shoulders)
The fetal head has been delivered but the shoulders are stuck and cannot be delivered
Dr Maryam

38. Definition
“…a delivery that requires additional obstetric maneuvers following failure of gentle downward traction on the fetal head to effect delivery of the shoulders.”
ACOG, Practice Bulletin 40 (November 2002)
Dr Maryam

39. Complications of Shoulder Dystocia
Complications can include:
Brachial plexus injury (overaggressive traction)
Impaired respiration  fetal hypoxia
Cord compression  compromised fetal circulation
Dr Maryam

40. GENERAL MANAGEMENT
Be prepared for shoulder dystocia at all deliveries, especially if a large baby is anticipated.
Have several persons available to help.
Dr Maryam

41. Shoulder dystocia cannot be predicted.
Dr Maryam

42. DIAGNOSIS
The fetal head is delivered but remains tightly applied to the vulva.
The chin retracts and depresses the perineum. 
Traction on the head fails to deliver the shoulder, which is caught behind the symphysis pubis.
Dr Maryam

43. Nursing Interventions
Dr Maryam

44. Intrapartum: Identify antepartum risk factors
Identify and report deviations from normal labor progress
Prepare for potential shoulder dystocia
Personnel
Supplies
Empty maternal bladder
Maternal positioning for birth
Dr Maryam

45. Birth:
Observe for “turtle sign”(after delivering the infant’s head, it retracts tightly against the perineum) or obvious resistance of the anterior shoulder
Document emergence of head
Call for help if not already there ( Code Blue )
Document any additional maneuvers attempted
Assist with maternal positioning
McRoberts
Suprapubic pressure (in direction indicated by provided)
Support mother about bearing down when instructed by provider
Record sequence and timing of events during birth
Accurately label fundal vs. suprapubic pressure in documentation
Dr Maryam

46. Assistant pushing flexed knees firmly towards chest
Dr Maryam

47. McRoberts Maneuver
Dr Maryam

48. If vaginal birth is not successful:
Prepare for immediate surgical birth
Continuously monitor fetus during the Zavanelli maneuver until birth
Dr Maryam

49. Post birth (Maternal):
Assess for
Hematoma
Uterine atony
Excessive bleeding
Bladder injury
Rectal injury
Provide explanations to family as needed
Document birth events
Dr Maryam

50. Neonatal: Neonatal resuscitation as needed Assess for broken clavicle
Assess for brachial plexus injury
Dr Maryam