COLLEGE OF MEDICINE

DEPT. OF OBSTETRICS AND GYNECOLOGY

Malpositions and
Malpresentations
Prof. Ayman Hussien Shaamash
MBBCH, MSc., MD. (Egypt)
Professor of OB./Gyn.
Faculty of Medicine- King khalid University
Abha- Saudi Arabia-
2011

Contents of the Lecture

Diagnosis of Malposition /Malpresentation
Malposition: Occiptoposterior
Malpresentations
I. Breech
II. Face
III. Brow
IV. Shoulder
V. Compound
VI. Cord presentation

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 Diagnosis of Malposition and
Malpresentation

3 2 1

Leopolds maneuver (abdominal palpation)

P/V examination (Denominators as occiput, mentum,
sacrum , scapula and Fontanelles as anterior or posterior)
Imaging ultrasound, rarely plain X-ray of abdomen

Malpositions

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 Occiptoposterior
Definition: where the fetus is lying longitudinally,
cephalic and the vertex is presenting, but it is not in the
OA
Incidence:20% of cephalic presentations.
Malposition
OT (LOT, ROT)
OP (ROP,LOP,DOP)
Commonest Types: R.O.P. 18 %
Common cause of non engagement
In primigravida

Long Anterior Rotation of OP

and SVD in EXTENSION

LT ROP

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 Mechanisms of delivery of ROP
1. Long Anterior Rotation of 3/8th of circle anteriorly to
direct occipitoanterior.SVD in 60%.
2. Anterior Rotation of 1/8th of circle (45)Deep
transverse arrest(rotation with ventouse or with
Kielland forceps may end with delivery otherwise
Cesarean section.)
3. Rotation of 1/8th of circle posteriorly to be direct
occipitoposteriormay deliver as face to pubis
(generous episiotomy as the diameter of delivery is
occipitipofrontal =11.5cm) or need Cesarean section.
4. It may persists as occipitoposterior, to be delivered by
Cesarean section.

Mechanism of delivery of OT
Occiptotransverse position
develops with Short Anterior
Rotation of the head 1/8th of
circle (45)Deep transverse
arrest [ROT or LOT]
Trial of Delivery with
ventouse or with Kielland
forceps may end with
delivery.
Otherwise Cesarean section.

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 Mechanism of delivery of DOP

Delivery of the head in DOP in FLEXION

Forceps Delivery Vacuum Extraction

Cesarean section in case of occipitoposterior:

1. If active management of labor fails as in : failure of

descent of the head or failure of full dilatation of the
cervix.
2. Failure of rotation , spontaneous OR with forceps or
ventouse.
3. Maternal or fetal distress.
4. Elderly primigravida.
5. Contracted or android pelvis

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 Malpresentations

I-Breech Presentation
Definition
Fetal buttocks or lower extremity is the presenting part
Complete (10%): flexion at hips and knees
Frank (60%): flexion at hips, extension at knees most
common type of breech presentation, most common
breech presentation to be delivered vaginally
Footling (30%): may be single or double with extension
at hip(s) and knee(s) so that foot is the presenting part
Epidemiology
occurs in 3-4% (at term)
BUT in 25-30% before 28 weeks

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 Types of Breech Presentations

Clinical Features
Diagnosis by Leopold's maneuvers (PPV of Le?pold's maneuvers is only 30%)

Risk Factors
I- Maternal risk factors:
Pelvis (contracted)
Uterus (shape abnormalities, intrauterine tumours, fibroids)
Extrauterine tumours causing compression
Grand multiparity
II- Placental-fetal risk factors:
Placenta (previa)
Amniotic fluid (poly/oligohydramnios)
Fetal prematurity (Commonest 30%)
Multiple gestation
1. Congenital malformations (6% of breeches; 2-3x incidence in vertex)
most common malformation:
malformation: congenital dislocation of the hip
2. Abnormalities in fetal tone and movement (IUFD)
3. Fetal aneuploidy

FLUPP: Fetus, Liquor, Uterus, Placenta and Pelvis

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 Management of Breech During Pregnancy
External cephalic version
Repositioning of fetus within uterus
Overall success rate of 65%
Criteria: >37 weeks, singleton, unengaged presenting part, reactive NST
Contraindications: previous T3 bleed, prior classical C/S, previous
myomectomy, oligohydramnios, PROM, placenta previa, abnormal US,
suspected IUGR, hypertension, uteroplacental insufficiency, nuchal cord
Risks: abruption, cord compression, PTL, PROM, bleeding, uterine rupture
Method: tocometry, followed by ultrasound guided transabdominal
manipulation of fetus with consistent fetal heart monitoring via real-time USS
If patient Rh negative, give Rhogarn prior to procedure
Good prognostic factors (for a successful version 65% or more)
1. multiparous
2. good fluid volume
3. small baby
4. skilled obstetrician

External Cephalic Version

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 Steps of External Cephalic Version

1 2

3 4

Vaginal Delivery of Breech Presentation

Criteria for vaginal delivery:
Frank or complete breech, GA >36 weeks
Estimated birth weight (EBW) 2500-3500 g based on
clinical and U/S assessment (5.5-8.5lb)
Fetal head flexed, by USS
Continuous fetal monitoring
Maternal pelvis adequately large (clinically, or
"proven" by previous delivery). NO trial delivery
2 experienced obstetricians, assistant, anesthetist,
neonatologist should be present

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 Hand gently
supporting
the emerging
breech
Keep the
sacrum
anterior

Delivery of the Legs - Optional Maneuver

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 Delivery of the Anterior Arm Gentle Traction on
in a Vaginal Breech Delivery Fetal Pelvis (groin)

Jaw flexion Shoulder Traction for Delivery of

the aftercoming head in breech presentation

Delivery of the aftercoming head in breech

presentation in FLEXION

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 Forceps Delivery for
aftercoming
Head..may be better?

Cesarean Section in Breech Presentation

C/S is indicated for :
(Contraindications for Breech Delivery)
1. Unfavourable pelvis
2. Footling breech
3. Hyperextension of fetal head,
nuchal arm
4. Macrosomia
5. Severe prematurity
6. Severe IUGR ,
7. placental insufficiency
8. Fetal anomalies
9. Lack of birth attendant skills
10. if the breech has not descended to the perineum in the second
stage of labour after 2 hours, in the absence of active pushing, or if vaginal delivery is not
imminent after 1 hour of active pushing
11. ?? all PG breech

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 Out come & Risks of breech Vaginal Delivery
Increased perinatal mortality and
Morbidity due to:
1) Intracranial hag.
2) cord prolapse, birth sphyxia
3) entrapment of the fetal head
through partly dilated cervix or
unrecognized disproportion
4) traumatic injuries
CNS, intra-abdominal, nerve
palsies, muscle injuries
5) extension of fetal arms (nuchal
arms)

II- Face presentation (0.2%)

Types and Etiology of face presentation:
A. Primary face presentation: i.e. it is present before labor.
1. Congenital malformations: 15% of cases.
o Anencephaly: It is one of the commonest causes of face,
o Fetal neck tumors as goitre or cystic hygroma.
o Dolicocephaly : Long anteroposterior diameter of the head
2. Spasm of the muscles of the back of the neck.
3 . Loops of cord around the neck.
4. Flat pelvis.
B. Secondary face presentation ,
in case of transient brow,
full extension turns into face

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 Management of face presentation.
Ultrasound is of value to exclude congenital malformation.
Mentoanterior :has a chance for SVD after long anterior rotation
(BUT in FEXION) , if no progression , trial forceps or Cesarean
section.
Mentoposterior :
1. If rotates 3/8th of the circle anteriorly SVD.
2.Persistant Mentoposterior or direct Mentposterior has no
chance for SVD and should be delivered by Cesarean section.

At diagnosis:
60% mentoanterior
15% mentotransverse
25% mentoposterior

Mechanism of Delivery of Mento-anterior

LMA, RMA, MT
The engaging diameters in a face
presentation are the Submento-
bregmatic (9.5cm) and biparital
diameter.
In case of face engagement is
considered when the chin is 2cm
below the ischial spine (station 2+).
The submento-vertical diameter
(11.5 cm) distends the perineum
during vaginal deliver
Forceps can be used to help anterior
rotation and delivery if 2nd. Stage is
prolonged. But cervical spine injury
is a serious complication
(Never try Vacuum)

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 Direct Mentoposterior (DMP)

NO mechanism of
delivery (obstructed
labor)
Cesarean section is
always indicated.

III- Brow Presentation

Incidence:: 1:1400
Mechanics of presentation:
Head is extended such that
attitude is halfway between
flexion (vertex) and
hyperextension (face)
Presenting part is between the
facial orbits and anterior
fontanelle (brow)

Usually transitional- when the head is in the process of converting

from a vertex to a face or vice versa
Supraoccipitomental (mentovertical) diameter is presenting 13.5cm;
[9.5cm for suboccipitobregmatic (vertex) or submentobregmatic (face)]

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 Management of Brow presentation in labour
Initially expectant;
50-75% will either flex to a vertex, or extend to a face with
contractions from behind meeting soft tissue and bony
resistance below and will therefore deliver vaginally
High incidence of prolonged labour and dysfunctional labour
Persistent brow
the diameter is undeliverable vaginally
deliver by caesarean section

IV-Shoulder Presentation
(Transverse lie)
Incidence: 0.3%
Mechanics of presentation:
long axis of the fetus is
perpendicular to long
axis of mother (ie occurs
in transverse lie)
Mostly the shoulder
presents in a transverse
lie, but alternative
presentations are hand
and arm (may be
prolapsed into the
vagina)

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 Aetiology:

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)

Diagnosis and Management

On abdominal palpation, no fetal pole is presenting to the pelvis,
and the head is palpable in either the right or left iliac fossa
on vaginal examination, may palpate ribs, scapula, clavicle
in advanced labour, fetal hand and arm may prolapse into the
vagina

Consider ECV prior to labour

if diagnosed in labour, deliver by Caesarean section (as fetal
head and trunk would have to enter pelvis at the same time to
deliver vaginally)
Caesarean may need to be classical, as lower segment often
inadequate

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 Neglected Shoulder Presentation
With Arm Prolapse

Pathologic Retraction Ring

Bulging Lower
Uterine Segment

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 V- Compound Presentation
Incidence: 0.1%
Mechanics of presentation:
When a fetal extremity prolapses
alongside the presenting part, and both
enter the maternal pelvis at the same time
vertex-hand

breech-hand

vertex-arm-foot

Aetiology
multiple- premature
Fetal:

Maternal: multiparity

MANGEMENT
Exclude cord prolapse
occurs in up to 20% of cases

Otherwise expectant
mostly doesnt 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

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 VI-Cord Presentation/ Prolapse

Cord below the presentating part with intact or ruptured membranes

Risk Factors:
Malpresentation, prematurity, polyhydramnios,
ARM with high presenting part, long cord

Epidemiology

Rapid Response to Cord Prolapse:

Recognize non-reassuring tracing
Visually inspect / palpate cord to diagnose
Assess fetal status (CTG, ultrasound)
Assess labour progress (dilatation, station)
Do not attempt to replace cord within uterus
Consider replacing cord within vagina, or wrap in
warm moist packs, if external
Hold presenting part off cord
Position change (Trendelenburg OR knee-chest)
Tocolysis
Prepare for Urgent delivery

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 THANK YOU

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