1. Malpresentation Dr. Abdalla H. Elsadig MD

2. Definitions Presentation: Presentation: Is the lowermost part of the fetus occupying the lower uterine segment ( cephalic, breech, hand, cord… etc). Is the lowermost part of the fetus occupying the lower uterine segment ( cephalic, breech, hand, cord… etc). Malpresentation: Malpresentation: includes all presentations other than cephalic. includes all presentations other than cephalic.

3. Why malpresentation? In vertex presentation the presenting part is a typical sphere (9.5 X 9.5 cm); this sphere will allow: In vertex presentation the presenting part is a typical sphere (9.5 X 9.5 cm); this sphere will allow: Production of equal uterine contraction → efficient uterine contractions. Production of equal uterine contraction → efficient uterine contractions. Production of equal cervical dilatation → well fitting presenting part. Production of equal cervical dilatation → well fitting presenting part. The membrane remain intact for a long time (6-8 cm). The membrane remain intact for a long time (6-8 cm). The cord will not prolapse. The cord will not prolapse.  In malpresentation: the presenting part is irregular, not fitting well to the cervix → complications during labour.

4. Breech Presentation Incidence: at term 3-4%, at 32 weeks 15% and at 28 weeks 20%. Types of breech: 1. 1. extended or frank (60-70%): the thighs are flexed at hip joints and the legs are extended the knee joints. 2. 2. Complete or flexed (25%): The thighs and legs are flexed at hip and knee joints 3. 3. Incomplete (10%): The fetal foot or knee is the lowermost presenting part

5. Etiology of breech presentation Etiology of breech presentation : Preterm delivery (major reason) Maternal factors: Uterine anomalies: bicornate… Pelvic mass: fibroids… ovarian... Anticonvulsant therapy. Drug /alcohol abuse. Fetal factors: IUGR/death. Congenital anomalies (esp. CNS): - anencephaly/hydrocephalus - Myelomeningocele. - prader-Willi syndrome Feto-maternal factors: Preterm delivery. Placenta praevia Multiple gestation Previous history of breech delivery. Polyhydramnios/oligohydram nios.

6. Diagnosis of breech presentation Abdominal palpation: Abdominal palpation: Fetal heart auscultation: Fetal heart auscultation: Ultrasound: Vaginal examination: Frank breech: - Ischial tuberosities, the sacrum and anus are palpable Complete breech - Feet are felt along side the buttock. Footling: - foot or knee is presenting

7. Management of breech presentation Antenatal management: Antenatal management: Fetal an d maternal assessment. Fetal an d maternal assessment. External cephalic version. External cephalic version. Breech delivery: Breech delivery: When? (Time of delivery):  Term/preterm delivery. How? (Mode of delivery):  Vaginal delivery: Spontaneous breech delivery Assisted breech delivery Breech extraction  Caesarean section

8. Antenatal management External cephalic version: 97.5% success rate. Benefits : 97.5% success rate. Indications: uncomplicated breech presentation after 37 week’s gestation. Indications: uncomplicated breech presentation after 37 week’s gestation. Absolute contraindications : Absolute contraindications : - multiple pregnancy – APH - multiple pregnancy – APH - Ruptured membrane. - Ruptured membrane. - fetal abnormalities. - fetal abnormalities. - cord around the neck. - cord around the neck. Relative contraindications: Relative contraindications: - previous C/S – maternal disease. - previous C/S – maternal disease. - maternal obesity BMI > 20% of the ideal. - maternal obesity BMI > 20% of the ideal. Risks of ECV: Risks of ECV: Procedure of ECV: Procedure of ECV:

9. Vaginal breech delivery Criteria: Frank or complete breech presentation with gestational age > 36 weeks. Estimated fetal weight of 2.5-3.5 kg. flexed fetal head. Extended head (due to nuchal cord, fundal placenta, neck muscle spasm, uterine abnormalities) associated with > 90% poor prognosis. Adequate maternal pelvis (Multiparous). No other obstetric complications: previous C/S, PET, diabetes, IUGR,…..etc. Preferably epidural analgesia. Well trained staff and equipped hospital.

10. Procedure of breech delivery Types of vaginal breech delivery: Spontaneous breech delivery Assisted breech delivery Breech extraction

11. Procedure of breech delivery First stage of labor - maternal and fetal monitoring - C/S if failure of progress or Fetal distress - Anaethesia (epidural ). - Oxytocin (? No)

12. Procedure of breech delivery Second stage of labor: -lithotomy position –episiotomy -Spontaneous up to umbilicus -Rotation to sacro-anterior. - pressure on popliteal fossa. -Cord is brought down. -Allow fetus to hang till to see posterior scapular - Deliver anterior schoulder or - Lovset’s manoevre.

13. Procedure of breech delivery Delivery of posterior arm

14. Procedure of breech delivery Delivery of the head - Mauriceau-Smellie-Veit maneuver

15. Procedure of breech delivery Delivery of the head Forceps delivery

16. Complications of breech delivery  Fetal complications: Intracranial haemorrhage Intracranial haemorrhage hypopiturarism. hypopiturarism. Medullary coning Medullary coning spinal cord severance. spinal cord severance. Brachial plexus injury Brachial plexus injury fracture of long bone fracture of long bone rupture of internal organs rupture of internal organs amage to male genitalia. amage to male genitalia. Damage to mouth and pharynx. Damage to mouth and pharynx. Occipital diastasis: impaction of occipital bone over pubic bone in second stage → separation of occipital bone, cerebellum damage, brain tissue herniation through foramen magnum, stillbirth or ataxic cerebral palsy.  Maternal complications: Soft tissue injuries Haemorrhage. infections

17. A real Slides For vaginal Breech Delivery

18. No action

20. episiotomy

22. Perineum support

25. Buttocks delivery

27. Legs delivery

28. Let baby to hang on weight

29. Anterior arm delivery

30. posterior arm delivery

31. Burn-Marshal manoeuvre

34. Third stage of labour