Malpositions of occiput and malpresentations

Dr Sanaa Abujilban, RN,RM,PhD

Objectives

• At the end of this lecture the students will be able to:
• Outline the causes of these positions
• Discuss the midwife’s diagnosis and management
• Describe the possible outcomes

Malpositions of occiput and malpresentations

• Occipito-posterior position
• Face presentation
• Brow presentation
• Breech presentation
• Shoulder presentation
• Unstable lie
• Compound presentation

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Types of Fetal Position

Position is the relationship of the presenting part to a specific quadrant of a woman's pelvis Figure 18-7: Fetal position. All are vertex presentations. A = anterior; L = left; O = occiput; P = posterior; R = right; T = transverse.

Occipito-posterior position

• Most common: 10% of labor

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Occipito-posterior position

• Causes:
• Unknown
• Abnormally shaped pelvis
• Antenatal diagnoses:
• Mother complains
• Backache
• High bottom of baby
• Fetal movements in abdomen sides

Occipito-posterior position�abdominal examination

• On inspection
• Saucer-shaped depression at or just below the umbilicus
• On palpation:
• Difficult to palpate the back
• Limbs felt on sides of the midline
• High head
• On auscultation:
• FHR in the midline

Occipito-posterior position�abdominal contour

Occipito-posterior position�antenatal preparation

• Knee-chest position several times a day (good evidence)
• Hands and knees position (insufficient evidence)

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Positions during pregnancy

Hand and knee position

Chest knee position

Occipito-posterior position:�diagnosis during labor

• Severe backache worsening with contractions
• Large and irregularly shaped presenting circumference
• Spontaneous ROM at early stage
• Incordinate contractions
• Slow decent of the head
• Early urge to push

Engaging diameter of the head: occipito-frontal

Occipito-posterior position�care in labor

• Keep the woman informed
• Take consent
• Long painful labor because of poor stimulation for contraction (head is high)

Occipito-posterior position�vaginal touch

Occipito-posterior position

• Midwife care in labor:
• Support the woman
• Massage
• Suggest Change posture and position
• All-four position (aid fetal rotation)
• Prevent dehydration and ketosis
• May need oxytocin infusion
• Relaxation will help in relieving the urge of pushing
• May give pain killer

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Occipito-posterior position�second stage of labour

• Confirm the full dilatation
• May have caput saccedaneum and moulding
• Encourage up right position to decent the head and shorten 2^nd stage
• May need oxytocin
• Observe maternal and fetal condition

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Moulding: upward moulding

Mechanism of labor

Occipito-posterior position: Possible outcomes

1. Long internal rotation
2. Short internal rotation:
1. Persistent occipitoposterior

Persistent occipitoposterior�Delivery of head

Occipito-posterior position: Possible outcomes

• 3. undiagnosed face to pubis
• 4. Deep transverse arrest
• Vaccum, forceps or C/S delivery
• 5. conversion to face or brow presentation
• Rare, more common in multiparous women

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Occipito-posterior position:�complications

1. Obstructed labor:
1. deflexed head or partially extended
2. Maternal trauma
• Perineal bruising and trauma
• 3^rd degree tear
3. Neonate trauma:
• Trauma because instrumental delivery
4. Cord prolapse:
• Because of high head and early ROM
5. Cerebral hemorrhage
• Because of upward moulding of the fetal skull or Chronic hypoxia

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2. Face presentation�six positions

• Figure 18- 4: Fetal attitude.

(a) Fetus in full flexion presents smallest (suboccipitobregmatic) anteroposterior diameter of skull to inlet in this good attitude (vertex presentation).

(b) Fetus is not as well flexed (military attitude) as in A and presents occipitofrontal diameter to inlet (sinciput presentation).

(c) Fetus in partial extension (brow presentation).

(d) Fetus in complete extension presents wide (occipitomental) diameter (face presentation).

2. Face presentation

• Complete extention
• Incidence:
• 1:500
• Types:
• Primary:
• Before labor
• Secondary:
• Developed from occiput posterior during labor

2. Face presentation�causes

1. Anteriour obliquity of the uterus
1. In multiparous women (week abdominal muscles) cause the change of fetal axis
2. Contracted pelvis:
• In andriod pelvis
3. Polyhydramnious
• Rush of fluid in ROM cause the extension
4. Congenital abnormality
• Anencephaly
• Tumor of the neck

2. Face presentation�intrapartum diagnosis

• On abdominal palpation
• Prominent occiput with a groove between head and back

2. Face presentation�intrapartum diagnosis

• On vaginal examination
• High, soft and irregular presenting part
• Adematous face mistaken with breech

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2. Face presentation;head diameter; submentobregmatic�submentovertical

2. Face presentation�outcomes of labor

1. Prolonged labor:
1. Ill-fitting head does not stimulate good contractions
2. Head enter pelvis with shoulders at the same time
2. Mentoanterior positions: birth safely as figure
3. Mentoposterior positions:
• if effective uterine contraction it become anterior
4. Persistent Mentoposterior positions:
• Incomplete extended head
• No further decent

2. Face presentation�birth of the head: mentoanterior

Persistent Mentoposterior positions

2. Face presentation�outcomes of labor

• 5. reversal of face presentation
• Manipulate the head to be occipitoanterior
• Done by Doctor
• Under the guidance of U/S
• By bimanual pressure after giving tocolytic and transvaginal pressure

Moulding in face presentation

2. Face presentation�management of labor

• 1^st stage:
• Inform doctor
• Routine observation for mother and baby
• Exclude cord prolapse after ROM
• Vaginal examination every 2-4 hrs
• If no descend need C/S

2. Face presentation�management of labor

• Birth of the head

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2. Face presentation�complications

1. Obstructed labor need C/S
2. Cord prolapse:
• caused by ill-fitting presenting part
3. Facial bruising
• Edema disappear in 1-2 days
• Lie with extended head
4. Cerebral hemorrhage
• Excessive pressure of the fetal head
5. Maternal trauma
• Perineal laceration
• Operative delivery

3. Brow presentation

• Partially extended head
• Presenting diameter is mentovertical : 13.5 cm

3. Brow presentation

• Causes: same as face presentation
• Diagnosis:
• On abdominal palpation:
• High head
• On vaginal examination:
• Anterior fontanelle, orbital ridges and root of the nose
• May have large caput succedaneum

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3. Brow presentation�management

• Inform the doctor
• Rare vaginal delivery: small pelvis with large head
• Keep mother informed
• May become face presentation
• Occasionally: flexion may occur
• Persistent brow: need C/S
• Complications: same as face presentation

3. Brow presentation�moulding in brow pres.

4. Breech presentation

• Lie: longitudinally
• Buttocks in lower pole of the uterus
• Presenting diameter is bitrochanteric (10cm)
• Vaginal birth is more hazardous than C/S birth

4. Breech presentation

Six Positions in breech

4. Breech presentation�

types

4. Breech presentation�causes

Unknown but it may due to:

• Extended legs of the fetus
• Preterm labor: before 34 weeks
• Multiple pregnancy
• Polyhydramnios
• Hydrocephaly: large head accommodate fundus
• Uterine abnormality: septum or fabroid
• Placenta previa

4. Breech presentation�antenatal diagnosis

• Abdominal examination:
• Mother feels something very hard under her ribs and causing shortness of breath
• Palpation:
• Difficult diagnosis in primi
• Soft presenting part
• In fundus: hard mass
• Auscultation:
• FHR above umbilicus
• May diagnosed by U/S and X-ray

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4. Breech presentation �diagnosis during labor

• Vaginal examination:
• Soft, irregular, no sutures palpable
• Sacrum mistaken with head and Buttocks mistaken with caput
• Fresh meconium
• May feel the genitalia
• May feel the foot

4. Breech presentation�Antenatal management

• Refer to doctor
• External cephalic version (ECV ) : Reduce the breech by 2/3
• Method:
• After 37 weeks
• U/S to confirm diagnosis
• Give tocolytic
• CTG for 30 min
• Empty bladder
• Supine position
• Put talcum powder and perform the ECV
• CTG again
• Ante-D if the woman RH -ve

4. Breech presentation�Antenatal management

• 1. External cephalic version
• Complications:
• Knotting of the umbilical cord
• Separation of the placenta
• Rupture of the membranes
• Contraindications:
• Pre-eclampsia or HTN : increase risk of abruption
• Multiple pregnancy
• Oligohydramnios: unsuccessful version
• Rupture membranes
• Conditions need C/S

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External cephalic version

4. Breech presentation�Antenatal management

• 2. moxi-bus-tion: need a welldesigned trial to evaluate it
• Dried mugwort herb used as a heat source
• Increase myometrial sensitivity and contractility
• Which in turn increase fetal movements
• Causing the fetus to turn
• Done around 34-35 wks
• Twice daily for 5 days
• 66-87 % the success

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4. Breech presentation�persistent breech

• Could not become cephalic
• Need to know if the head could be birthed vaginally
• Need good assessment of:
• Pelvic capacity
• Fetal size

4. Breech presentation�management of labor

• 1^st stage:
• Exclude cord prolapse
• Meconium- stained liquor is found
• Analgesia: Epidural block
• 2^nd stage:
• Obstetrician and pediatrician should attend
• No pushing till full dilatation
• If no descend in 2^nd stage: need C/S

4. Breech presentation�types of birth

• Spontaneous
• Assisted breech
• Breech extraction: by obstetrician

4. Breech presentation�birth of the shoulders

4. Breech presentation�birth of the head

• Methods used
• Forceps delivery
• Burns Marshal method:
• Undertaken once the nape (back of the neck) of the neck and hairline are visible
• Mauriceau-Smellie-Veit maneuver:
• Used when there is a delay in descent of the head because of extension

Forceps delivery

Burns Marshal method

Mauriceau-Smellie-Veit maneuver

4. Breech presentation�delivery of the extended legs

4. Breech presentation�delivery of extended arms�Lovset manouver grasp

Lovset maneuver for the �delivery extended shoulder: �rotation and downward

4. Breech presentation�complications

1. Impacted breech: obstructed labor
2. Cord prolapse: common in a flexed or footling breech
3. Superficial tissue damage: edema and bruising of baby limp and genitalia
4. Fractures of humerus, clavicle or femur or dislocation of shoulder or hip:
1. During manipulation
5. Erb’s palsy
• By twisting the baby’s neck

4. Breech presentation�complications

1. Trauma to internal organs:
• from grasping the abdomen
6. Damage to the adrenals
• from grasping the abdomen
7. Spinal cord damage or fracture of the spine:
• From bending the body
8. Intracranial hemorrhage
• From rapid birth of the head or hypoxia
9. Fetal hypoxia: from cord prolapse
10. Premature separation of the placenta
11. Maternal trauma

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5. Shoulder presentation�only 17% remain as transverse

5. Shoulder presentation: causes

• maternal:
• Lax abdominal and uterine muscles:
• In multigravida
• Uterine abnormality:
• Bicornuate or supseptate or fibroid
• Contracted pelvis
• Fetal:
• Preterm labor: more fluid
• Multiple pregnancy: polyhydramnios
• Polyhydramnios
• Macerated fetus: no muscle tone
• Placenta previa

5. Shoulder presentation:�antenatal diagnosis

• On abdominal examination:
• Broad abdomen
• Less than normal fundal height
• No head or breech on fundus
• Diagnosed by U/S

5. Shoulder presentation:�intrapartum diagnosis

• On abdominal examination:
• If ROM: Irregular outline of the uterus
• On vaginal examination:
• Shoulder: soft irregular mass

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5. Shoulder presentation

• Birth: no vaginal delivery: need C/S
• Antenatal:
• If pelvis is adequate and no placenta previa need external cephalic version
• Intrapartum
• If membrane intact do ECV
• If ROM check for prolapse and then urgent C/S

5. Shoulder presentation

• Immediate C/S if:
• Cord prolapse
• ROM
• Unsuccessful ECV
• Labor started for hrs

5. Shoulder presentation�complications

• Prolapsed cord
• Prolapsed arm: need immediate C/S
• Neglected shoulder presentation
• Arm edematous and blue
• Tonic contraction
• May absent heart beat
• Obstructed labour
• May rupture uterus and still birth
• Treatment: C/S

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6. Unstable lie

• After 36 wks lie varies from one examination to another
• Causes:
• Maternal
• Lax uterine
• Contracted pelvis
• Fetal:
• Polyhydramnios
• Placenta previa

6. Unstable lie�management

• Antenatal:
• May need admission
• Educate the woman about ROM and cord prolapse
• U/S: If no placenta previa may have ECV
• Intrapartum:
• Induce labor after 38 wks if longitudinal
• IV Fluid and oxytocin
• Then: Empty bladder and rectum
• Then: Controlled ROM
• If labor started with transverse: same complications

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7. Compound presentation

• Hand or foot lies alongside the head
• Occur with small fetus or roomy pelvis
• Emergency
• Try to hold the hand back

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