1. ABNORMAL PRESENTATION
& BREECH
DR. IQBAL TURKISTANI
ASST. PROF. & CONSULTANT

2. Malpositions & Malpresentations  carry an increased risk for both mother and fetus
Maternal risks:
- Prolonged labour infection
- Obstructed labour
- General anaesthesia at short notice, when the mother is in poor condition
- Difficult vaginal delivery or C.S. trauma leading to haemorrhage
- Damage to pelvic veins resulting to venous thrombosis and fatal pulmonary embolism in the puerperium

3. In developing countries  obstructed labour may cause tissue necrosis vesico- vaginal and recto-vaginal fistula.
 Perinatal mortality and morbidity:
 due to fetal malformation
 intrauterine death
 extreme prematurity
 cord prolapse +
malpresentation Potent
 abnormal uterine action causes
and prolonged or obstructed of fetal
labour hypoxia
 Fetus at risk of infection (: prolonged ROM)
and also meconium aspiration

4. Significant proportion of ruptured uterus still result into maternal deaths from unwise management of malpresentation or malposition
Therefore, for optimal result/safe labour and delivery:
 Early diagnosis by skilled assessment
 Plan delivery by experienced staff
 Working in proper surrounding
 Experienced anaesthesia must be available for
these most difficult cases
 Close supervision and full use of available
monitoring methods ..if vaginal delivery is
planned
 Facilities to perform immediate operative
delivery or caesarean section are mandatory
 Review of progress and necessary intervention
by senior staff members is the rule

5. LIE, PRESENTATION POSITION
The relationship of the long axis of the foetus to that of the mother
LONGITUDINAL
TRANSVERESE & OBLIQUE (Shoulder present.)
CAUSES:
 High multip.  Hydramnious
 Pre-term lab  Obstructing tum. Or
 Multiple Preg Plac. previa
 Ut. Anomaly  Severe pelvic contraction
MANAGEMENT:
 Antenatal  Intrapartum

9. PRESENTATION
That part of the foetus that is foremost in the birth canal, or closes to it.
A. Cephalic
B. Breech
C. Shoulder
D. Compound

10. CEPHALIC PRESENTATION
Vertex 96% (suboccipito – bregmatic= 9.5 cm)
SINCIPUT (occipito – frontal = 11.5 cm)  OP
BROW 1:1050 (mento- vertical = 13 CM)
CAUSES:
- Chance
- Neck swelling e.g. goiter or cystic hygroma
- Spasm of sternomastoid muscle
DX:
- Ant. fontanell & supraorbital ridge (pv)
- XR (lat)
FACE 0.3% (Submentobregmatic = 9.5 cm)
- Palpation of supraorbital ridges &
aveolar margins (confusion with breech)

11. BREECH PRESENTATION CAUSES: ASSOCIATED FACTORS: Frank Breech 65%
Complete Breech 25%
Footling Breech 10%
CAUSES:
Extended legs preventing spont. version
Those conditions preventing fetal presenting parts entering pelvic cavity.
Uterine anomaly
Chance
ASSOCIATED FACTORS:
Fetal anomaly
Preterm delivery
Multiple pregnancy

16. ANTENATAL MANAGEMENT
ECV:
Hazards:
Preterm Labour
Abruption
Cord accident
Ut. Rupture (prev. C.S.)

17. CONTRAINDICATIONS: Absolute: Relative:  Multiple preg.  APH
 Rupt. Membrane
 Oligohydramnios
 Significant fetal anomaly
 C.S. indicated for other reasons
Relative:
 Prev. C.S
 IUGR
 H.T
 Rh. Isoimmunization
 Grand multip
 Ant. Placenta
 Obesity

18. MANAGEMENT OF DELIVERY
Pre-delivery assessment:
 Pelvic dimension (clinical & XR ~37wks)
 USS of BPD, fetal mass, attitude & flex/ ext. of head)
 Major fetal anomalies to be excluded

19. VAGINAL DELIVERY:  Term (fetal wt. 2.5-3.5 kg)  Frank breech
 Normal pelvis
 No other complic. of preg. (e.g. PET)
 Normal FHR & BPP
 Epidural
C.S.

20. FREQUENCY:
VERTEX 96%
BREECH 3.5%
FACE 0.3%
SHOULDER 0.2%

21. POSITION:
Refers to the relation of an arbitrarily chosen portion of the presenting part of the fetus, to the right or left side of the mother :
VERTEX …... OCCIPUT-- LO., RO
FACE ……CHIN (mentum)-- LM., RM
BREECH ….. SACRUM -- LS., RS
SHOULDER … ACROMION OR SCAPULA

22. OP POSITION:
If baby’s head is partially extended it does not fit into the lower ut. pole well with the following consequences in labour:
Early ROM & Cx. not well opposed to head.
Sinciput reaches pelvic floor first & therefore rotates to front i.e. occiput is post.
Large occipito frontal diam. of head presents (10 cm)  more difficult to pass.
1st stage of labour is prolonged.
Movements of forces pushes head posteriorly causing backache & inducing bearing down efforts before full dilatation
2nd stage of labour may be prolonged.

23. Or Persists posteriorly (POP) (5%)
THE OCCIPUT may rotate anteriorly & deliver relatively easily (75%)
Or Persists posteriorly (POP) (5%)
 spontaneous delivery if pelvis is capacious (face to pubis)
 or requires assisted delivery
Or Begins to rotate ant. but undergoes deep transverse arrest at level of ischial spines  instrumental delivery may be required (20%)

24. PREDISPOSING FACTORS:
- Slight reduction in pelvic inlet
- Large baby
DIAGNOSIS:
- Antenatally
- During labour (both fontanells easily palpable)

25. MANAGEMENT: ♣ Epidural/ adeq. analgesia
♣ Prevent maternal ketosis & dehydration
♣ Monitor fetal well being
♣ R/O relative CPD