1. MALPRESENTATION
&MALPOSITION

2. LECTURE OVERVIEW Abnormal lie, malpresentation and malposition
Malpresentation and its management
breech
face
brow
shoulder
compound

3. DEFINITIONS Abnormal lie
where the long axis of the fetus is not lying along the long axis of the mother
LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH)
TRANSVERSE
OBLIQUE
UNSTABLE

4. DEFINITIONS Malpresentation
where the fetus is lying longitudinally, but presents in any manner other than vertex
BREECH
FACE
BROW
SHOULDER
COMPOUND
CORD

5. DEFINITIONS Malposition
where the fetus is lying longitudinally and the vertex is presenting, but it is not in the OA position
OT (LOT, ROT) OP

6. DEFINITIONS Malpresentation
where the fetus is lying longitudinally, but presents in any manner other than vertex
BREECH
FACE
BROW
SHOULDER
COMPOUND
CORD

7. MANAGEMENT OF BREECH PRESENTATION AT TERM
Management options
(1) external cephalic version
(2) elective caesarean section
(3) trial of vaginal delivery

8. EXTERNAL CEPHALIC VERSION
CONTRAINDICTAIONS:
3rd trimester bleeding
uterine anomalies
ROM, oligohydramnios
need for CS for other reasons (placenta praevia, contracted pelvis, hyperextended head)
indicated vaginal delivery (fetal death, anomaly best delivered as breech)

9. EXTERNAL CEPHALIC VERSION
SUCCESS
60-70%
TECHNIQUE
after 36W
CTG prior
attempt to perform forward somersault
tocolytic
CTG after (8% bradycardia; 5% fetomaternal haemorrhage)
anti D (if Rh negative)

10. ELECTIVE CAESAREAN SECTION
EFW <2500g; >3500g
preterm breech
hyperextended fetal head
palcenta praevia
concerns re. fetal well being, including oligohydramnios
footling breech
10% risk of cord prolapse
?complete breech
5% risk of cord prolapse (c.f. 1% with frank breech)
?all PG breech

11. CRITERIA FOR VAGINAL DELIVERY
Frank or complete breech
EFW g
gestational age >36 weeks
fetal head must be flexed
maternal pelvis must be adequate
judged clinically or by pelvimetry
no other maternal or fetal indiaction for CS
experienced obstetrician, anaesthetist and paediatrician present at delivery

12. FACE PRESENTATION
Incidence: 0.2%
Mechanics of presentation:
Characterized by extreme extension of the fetal head so the face (rather than the skull) presents to the birth canal
Aetiology
any factor that favours extension such as fetal goitre, anencephaly
high maternal parity
At diagnosis:
60% mentoanterior
15% mentotransverse
25% mentoposterior

13. BROW PRESENTATION
Incidence: 1:1400
Mechanics of presentation:
head is extended such that attitude is halfway between flexion (vertex) and hyperextension (face)
usually transitional- when the head is in the process of converting from a vertex to a face or vice versa
presenting part is between the facial orbits and anterior fontanelle
supraoccipitomental diameter is presenting 13.5cm; cf 9.5cm for suboccipitobregmatic (vertex) or submentobregmatic (face)

14. AETIOLOGY prematurity, multiple polyhydramnios anomaly praevia
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)

15. MANGEMENT occurs in up to 20% of cases
Exclude cord prolapse
occurs in up to 20% of cases
Otherwise expectant
mostly doesn’t interfere with normal delivery
vertex-foot: try to gently reposition the lower extremity
if arm prolapses in vertex-hand, wait and see if it moves as head descends; if it converts to shoulder presentation, deliver by CS

16. SUMMARY Abnormal lie, malpresentation, malposition
Incidence, mechanics, aetiology, diagnosis, management of
BREECH PRESENTATION
FACE PRESENTATION
BROW PRESENTATION
SHOULDER PRESENTATION
COMPOUND PRESENTATION