Malpresentation and Malpostion

Malpresentation and Malpostion

Mal-presentation - A presentation other than vertex Eg. Shoulder, face, brow and breech

Mal-position and mal-presentations have ill fitting presenting parts compared to a well flexed vertex presentations in a normal pelvis.

Causes: - polyhydraminous

·                 Abnormality of pelvis

·                 Abnormal shape of uterus

·                 Laxcity of uterine muscles

·                 Multiple pregnancy

All ill fitting part is associated with (results in):

·                 Early rupture of membrane with risk of cord prolapsed

·                 Premature labour

·                 Slow, irregular, short-lived contractions

·                 Uncoordinated and excessively painful labour after rupture of membranes

·                 Prolonged and obstructed labour

·                 Post partum hemorrhage

·                 Fetal and maternal distress

1.  Breech Presentation

Definition: When the fetus lies with his buttock in thelower pole of the uterus.

It occurs in 1: 40 cases of labor after 34 weeks

·                 Breech with extended legs or frank breech- in this type of breech the thighs are flexed and the legs are extended along the fetal abdomen. It is the common one.

·                 Complete breech the fetus lies in a flexed attitude and the legs are flexed on the abdomen. The presenting part is bulky and consists of buttocks external genitalia and both feet.

·                 Footling- one or both feet present because neither hips nor knees are fully flexed. 

·                 Knee presentation. On this case both the hips are extended with the knees flexed.

Example

Lie-Longitudinal

Attitude-complete flexion

Presentation- Breech

Position- Leff sacro Anterior

Donominotor- Sacrum

Presenting part- is anterior buttock

Causes:-often no cause is identified but the followingcircumstances favor breech presentation.

·                 Poly hydromnios

·                 Prematurity

·                 Multiple pregnancy

·                 Placenta preveia

·                 Contracted pelvis

·                 Uterine abnormalities

·                 Hydrocephalus

·                 Extended legs

Diagnosis

On palpation

·                 Lie is longitudinal

·                 The fundus contains a firm, smooth and rounded mass which dependently moves with the back.

·                 On pelvic palpation no head is palpated pelvic has a soft and irregular mass.

On auscultation

The fetal heart beat is heard above the umbilicus if the breech is not engaged below the umbilicus if it is engaged.

Vaginal examination

No sutures and fontanels are felt. When the membrane are ruptured the anal sphincter grips the finger when fresh meconeum seen on the examining finger. 

Antenatal management

The presentation may be confirmed by ultrasound scan or X-ray of abdomen. The obstetirician may decide to do an external cephalic version before 36 weeks of gestation.

Management in labor

The method of delivery is chosen depend on

1.              Parity of the mother if she is preimigravida

2.              Size of the baby

3.              Other obstetrical complication

The Principles of Management

·                 Intelligent observation

·                 Avoidance of unnecessary interference

·                 Prompt action carried out with manual dexterity when assistance is needed

·                 Avoidance of fetal injury and hypoxia

Mechanism of breech delivery

Descent takes place by increasing compaction due to increased flexion of the limbs. Bitrochantric diameter which is 10cm enters the pelvis in the oblique diameter.

·                 Internal rotation of the buttocks

·                 Lateral flexion of the body

·                 Restitution of the buttock

·                 Internal rotation of the head.

·                 External rotation of the body

·                 Birth of the head the chin face and sinciput sweep the perineum and the head is born in a flexed attitude. N.B. Labor in breech is always considered as a trial

Management of Labor in Breech Delivery

It is managed depending on types of presentations

Types of delivery

·                 Spontaneous breech delivery

·                 Assisted breech delivery-assistances for delivery of extended legs arms and the head.

·                 Breech extraction this is the manipulative delivery to extract the breech when the mother is unable to deliver.

First Stage

·                 Careful observation

·                 Warn mother not to push

·                 Vaginal examination when membrane ruptures (to rule out cord prolapse).

·                 Sedation often necessary

·                 Be prepared for the delivery

Delivery of Flexed Breech

Full dilatation of the cervix should be confirmed by vaginal examination before allowing the woman to push to prevent the breech slipping through incompletely dilated and the head may be trapped by the cervix.

Active pushing is not commenced until the buttocks are distending the vulva.

·                 Encourage her to push with the contraction and the buttocks are delivered spontaneously episiotomy may be necessary

·                 The hands off the breech get mother to push when the buttocks are born pull down a loop of cord feel for pulsation put in to the hollow of the sacrum to prevent pressure and traction.

·                 Fell for the elbows on the chest the shoulder should be born easily with the arms flexed across the chest if not help them out by flexing the arm.

·                 Grasp the baby by iliac crest with the thumbs held parallel over his sacrum and tilt the baby towards the maternal sacrum to free the anterior shoulder.

·                 Wrap small towel around the baby hip to preserve the warmth and improve the grip on the slippery skin.

·                 When the anterior shoulder is born lift the buttocks towards the mother’s abdomen to enable the posterior shoulder to pass over the perineum.

Delivery of the head

Delivery of flexed head (Burn’s Marshal Method)

After the shoulder is born the baby is allowed to hang unsupported. With in one minute the nape of the neck (hair line) appears. The baby is now grasped by the ankle and maintains traction while supporting the head on the perineum with the right hand. Hold the baby on a stretch and slowly bring the feet up to an angle of 180 degrees.

When the face appears get some one to clean the air ways then delivery the head very slowly taking 2 to3 minutes to allow the vault of the head to be expelled. The mother should breathe out the head.

Delivery of extended head (mauriceau smelle’s veit method)

When the baby is allowed to hang the neck and hair line is not visible, it indicates that the head is extended.

Pick up the baby by the feet and lie him astride on the right forearm put the middle finger of the right hand in the babies mouth far back to the roof of the tongue. With the other hand on the head and flex it down wards to wards the floor applying traction. When the head is down bring it up gently delivery slowly taking 2 to 3 minutes to deliver it and so prevent cerebral damage

Delivery of extended breach

Get mother to push, when legs are seen it may be necessary to apply slight pressure in the popliteal space beyond the knee. This will flex the legs and then they can be easily delivered. Pull down a loop of cord to prevent traction, feel for pulsation, and place it in the hollow of the sacrum to prevent pressure. 

Delivery of extended arm

Get mother to push, when the axilla is seen it means that the arms are extended. So place the cord sacrum and fingers below the iliac crest, rotate shoulder in to the anterior posterior diameter of the pelvis, then rotate the posterior shoulder anteriorly keeping the back on top, now flex the arm over the face and deliver it, splint it, and now bring the other arm anteriorly, and deliver it by flexing it across the chest now the shoulders are born.

Dangers of breech presentation

i.            Delay of the after coming head

ii.            Cerebral damage due to hypoxia

iii.            Asphyxia (fetal or neonatal), prolapsed of cord or pressure on cord.

iv.            Permaturity

v.            Intracranial hemorrhage due to trauma

vi.            Injuries to liver spleen adrenal glands or kidney

vii.            Erb’s palsy due to damage of the brachial plexus

viii.            Facial nerve paralysis due to the twisting of the neck.

ix.            Fracture to femur, tibia, humorous or clavicle

x.            Damage to spinal cord due to wrong handling

xi.            Pneumonia due to premature inspiration.

2. Brow Presentation

Definition:- When the sinciput or the area between the face and vertex is in the lower pole of the uterus.

Attitude – Between flexion and extension (mid way) engaging diameter mentovertical 13:5cm. It occurs 1 in 1000 deliveries

Causes:

·        Lax uterus, multiple pregnancy, hydraminous

·        Deflexed fetal head

Hypotonus of the neck muscle

Thyroid tumor

·        Anencephaly

·        Abnormal shape of pelvis

Diagnosis

On palpation – the head is big and high & does not enter thepelvis

On vaginal examination

·        It is difficult to touch the presenting part

·        A smooth hair less area is felt, with part of the bergman at one side

·        The orbital ridges may be felt.

Management

If brow presentation is diagnosed early in labour, it may be converted to a face presentation by fully extension or it may be flexed to a vertex presentation, however, brow presentation will lead to obsetructed labour.

i.            Cesearian section is the management for alive baby

ii.            Craniotomy if baby is dead.

3. Shoulder Presentation

Definition- When the shoulder of the fetus lies in the lower pole of the uterus in labour. A transverse lie becomes a shoulder presentation in labour. Incidence-Occurse once in 250-300 deliveries.

Causes

·        Laxity of uterus

·        Placenta previea, hydraminous,

·        Multiple pregnancy

·        Uterine abnormality

·        Preterm pregnancy

Diagnosis

·        The uterus appear broad and the funds height is less than expected for the period of gestation

·        Easily seen on abdominal examination. When labour progresses, the hand can be felt or the ribs on V.E.

·        Arm may prolapsed when membrane rupture ultrasound

Management

·        When diagnosed at antenatal clinic after 36 weeks external version will be attempted

·        In labour caesarian section is method of choice when attempt of external version have failed.

·        When membrane have ruptured before; if there is cord prolepses if arm prolepses even with dead fetus ceaserian section is mandatory.

4.  Face Presentation

Definition: When the attitude of the head is extensionand the face lies in the lower pole of the uterus.

Cause

·        Lax uterus, multiple pregnancy

·        Hydraminous

·        Deflexed fetal head

·        Ancephaly

·        Abnormal shape of pelvis

Diagnosis

Abdominal examination

Inspection- irregular abdomen and the shape of the fetal spine is that of an” S.”

Palpation

prominent occiput is felt on one the same side as the sinceput which is lower than the occiput. A deep groove is felt between fetal back and head Auscultation- the fetal heart is heard clearly at midline

Vaginal examination

·        The presenting part is high

·        A soft irregular mass is felt, the gums are felt and the fetus may examining finger - diagnostic

·        Noting the position of mentum is important i.e Anterior, transverse or posterior

Mechanism of face delivery

·        Instead of an increase in flexion there is an increase in extension

·        The chin rotate instead of occput

·        The engaging diameter is sub mentobregmatic 9.5 cm face presentation can be born normally except when the chin is posterior and gets caught in the hollow of the sacrum, when it develops into obstructed labour.

Management in labour

·                 Encourage and perhaps sedate because she will have extra discomfort.

·                 When membranes ruptures do vaginal examination to make sure no cord prolapsed and to note the position

·        Rotation occurs below the level of spines

·        If the chin is anterior let labour continue, if transverse, watch that it rotates anteriorly. When the face distends the perineum, perform an episiotomy, then hold back the sinciput and allow the chin to be born, when the chin is born flex the head and allow the occupt to be born.

·        Always be careful not to damage the baby’s eyes with fingers or antiseptic

Complications

·        Obstructed labour

·        Cord prolapse

·        Facial bruising

·        Cerebral haemorrhage & Maternal trauma

5.  Unstable lie

Definition:-When the lie is found to vary, breech, vertex orshoulder, presenting from one examination to another after 36^th weeks of pregnancy.

Causes

·        Lax uterine muscles

·        Multiparity

·        Poly hydraminous

Management

Admission in hospital at the 36-37 week and remain in the hospital until delivery.

Attempts are made by the obstetrician to correct the abnormal presentation by external version. If unsuccessful, caesarian section is considered. Some times AROM is done after correcting the transverse lie to ensure that the woman goes into labour with vertex presentation. An oxytocic drip is usually given after version.

·        Extreme caution and close observation is mandatory throughout labour.

·        Monitoring of Fetal Heart Beat frequently is very important

·        The bladder and the rectum should be emptied to facilitate

·        preservation of the longitudinal lie.

6. Compound or Complex Presentation

Definition: - When a hand or occasionally of foot, liesalong side the head. This tends to occur with a small fetus or roomy pelvis seldom is difficulty encountered except in cases where it is associated with a flat pelvis. On rare occasions head, hand & foot are felt in the vagina, a serious situation which usually occurs with a dead fetus.

If diagnosed during the first stage of labour, attempt could be made to push the arm up words over the baby’s face. If during the second stage hold the hand back directing it over the face.

7.  Occupition Posteririor Position

It is a malposition of the head, occurs in 13% of the vertex presentations. Head is deflexed-larger diameter present.

Causes

Direct cause is unknown but associated with

·        Pendulous abdomen

·        Abnormal pelvis, Androld, Anthropoid, flat sacrum

·        The placenta is in anterior wall

Diagnose

Inspection

Deep hollow between head and lower limbs

Palpation

The fetal head is found on one side

The limbs are infornt and give hollowing above the head. There is a saucer like depression around the umbilicus. There is a bulge like full bladder occiput and sinciput are at the same level. Limbs are found on both sides.

Auscultation

Fetal Heart is heard in the flanks and descends down

Vaginal examination

·        Membranes may rupture early

·        If infant may protrude through cervix as a finger like fore water or fill up the upper vagina

·        Due to deflection, anterior fontanel is felt in the anterior part of the pelvis near ileo pectineal eminence

Out Come

·        If the flexion of the head increases the occiput strikes the pelvic floor and rotates anteriorly (ROP) to 45 then to 90⁰ rotation and dilvered normally.

·        If the flexion remains incomplete, the rotation of the head takes place posteriorly brings the occiput in the hollow of the sacrum. This is known as short rotation.In this case the baby is born by face to Pubis.

·        Some  times  the  long  rotation  of  occipitoposterior  is arrested and the head is left in the Occipito- lateral position in the cavity of the pelvis.

Occipito frontal diameter is caught at the narrow spinous diameter of the outlet.This is known as deep transverse arrest or persistent occiptoposterior. The delivery could be by rotation of the head to anterior or by cesarean section.

Management

Encourage the mother to lie on the side where the fetus lies. Patient may have sever back pain analgesics may be given. Retention of urine is common catheterization is necessary. Patient feels the need to bear down before fully dilation. Two-third of cases will deliver normally.12% will deliver face to pubis. If the ischial spines are prominent the internal rotation may interrupted caesarian section is recommended.

Identifying the ear by the root of the pinna (right or left) manual rotation can be done by, keep the right hand on the head and left on the abdomen and rotate than forceps delivery is performed.