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MALPOSITION AND MALPRESENTATION

Mrs. K.PunithaLakshmi,M.Sc (N)

Principal, JIET College of Nursing

Jodhpur

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Definition of Position

Position is the orientation of the fetus in the womb, identified by the location of the presenting part of the fetus relative to the pelvis of the mother.

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Presentation

Presentation of a fetus about to be born refers to which anatomical part of the fetus is leading, that is, is closest to the pelvic inlet of the birth canal. According to the leading part, this is identified as a cephalic, breech, or shoulder presentation.

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Malpositions are abnormal positions of the vertex of the fetal head (with the occiput as the reference point) relative to the maternal pelvis.
Malpresentations are all presentations of the fetus other than vertex.

PROBLEM

The fetus is in an abnormal position or presentation that may result in prolonged or obstructed labour.

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TERMINOLOGY

Vertex

The area of the skull between the anterior and posterior fontanelles, and the parietal eminence Top of the skull

Occiput

Back of the fetal head behind the posterior fontanelle

Sinciput

That part of the fetal head in front of the anterior fontanelle.-forehead or brow

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Causes of Malpresentations and Malpositions

1.Defects in the powers
Pendulous abdomen: laxity of the abdominal muscles
Dextro-rotation of the uterus: rotation of the uterus in anti-clock wise favours occipito-posterior in right occipito-anterior position

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2. Defects in the passages
Contracted pelvis.
Android pelvis.
Pelvic tumours.
Uterine anomalies as bicornuate, septate or fibroid uterus.
Placenta previa.

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3.Defects in the passenger
Preterm fetus.
Intrauterine fetal death.
Macrosomia.
Multiple pregnancy.
Congenital anomalies as anencephaly and hydrocephalus.
Polyhydramnios.
Coils of the cord around the neck favours face presentation.

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Anterior insertion of the placenta: the fetus usually faces the placenta (doubtful).
Other causes of malpresentations: as
a. placenta praevia,
b. pelvic tumours,
c. pendulous abdomen,
d. polyhydramnios,
e. multiple pregnancy.

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Classification�

Thus the various presentations are:
cephalic presentation (head first):

vertex (crown) — the most common and associated with the fewest complications
sinciput (forehead)
brow (eyebrows)
face
chin

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breech presentation (buttocks or feet first)

complete breech
footling breech
frank breech

shoulder presentation

arm
shoulder
trunk

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Signs of Malpresentations

Pendulous abdomen.
Non-engagement of the presenting part in the last 3-4 weeks in primigravida.
Premature rupture of membranes or its rupture early in labour.
Delay in the descent of the presenting part during labour.
Vaginal examination, X-ray or ultrasonography are more conclusive.

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Normal Position

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Presentation and Position

Cephalic presentation

Vertex presentation with longitudinal lie:

Left occipitoanterior (LOA)—the occiput is close to the vagina (hence known as vertex presentation) faces anteriorly (forward with mother standing) and towards left. This is the most common position and lie.

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Right occipitoanterior (ROA)—the occiput faces anteriorly and towards right. Less common than LOA, but not associated with labor complications.
Left occipitoposterior (LOP)—the occiput faces posteriorly (behind) and towards left.
Right occipitoposterior (ROP)—the occiput faces posteriorly and towards right.

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Occipitoanterior —the occiput faces anteriorly (absolutely straight without any turning to any of the sides)
Occipitoposterior —the occiput faces posteriorly (absolutely straight without any turning to any of the sides)

Face presentation

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Occipito Posterior Position

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Transverse Position

This LOT (Left, Occiput, Transverse) position and its' mirror image, ROT, are common in early labor.
As labor progresses and the fetal head descends, the occiput usually rotates anteriorly, converting this LOT to an LOA or OA as the head delivers.

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Transverse Position

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Breech presentation with longitudinal lie:

Left sacrum anterior (LSA)—the buttocks, as against the occiput of the vertex presentation, like close to the vagina (hence known as breech presentation), which like anteriorly and towards the left.
Right sacrum anterior (RSA)—the buttocks face anteriorly and towards the right.

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Left sacrum posterior (LSP)—the buttocks face posteriorly and towards the left.
Right sacrum posterior (RSP)—the buttocks face posteriorly and towards right.
Sacrum anterior(SA)—the buttocks face anteriorly.
Sacrum posterior (SP)—the buttocks face posteriorly.

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Shoulder presentation with transverse lie are classified into four types, based on the location of the scapula (shoulderblade); note: this presentation needs to be delivered by caesarean section.

Left scapula-anterior (LSA)
Right scapula-anterior (RSA)
Left scapula-posterior (LSP)
Right scapula-posterior (RSP)

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Face Presentation�

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Full extension of the head
Presenting part: Face
Denominator: Omentum/Chin
Diameter; Sub-mento bregmatic 9.5cm
Presentation - Mento anterior– Vaginal delivery

-Mento posterior- Ceasaeran section

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Causes

Anenecephaly
Prematurity
Multifetal pregnancy
Polyhydramnious
Neck tumours
Sternomastoid spasm
Multiparty

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Brow Presentation

1:800, 1:2000 deliveries
The area between the orbital ridge and the anterior fontenalle
Most unfavourable of all presentation
Transient presentation

Full flexion—Occiput

Full extension---Face

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Shoulder presentation