Shoulder,Face ,Braw presention.,Compound presention for undergraduate

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MALPRESENTATION
DR MANAL BEHERY Assistant Professor, Faculty of
Medicine, Zagazig University
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Defintion
Definition

• Fetal presenting part other than vertex includes
  breech, face, brow, transverse, and compound
  presention.

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Related Factors

• More than one pregnancy
• (e.g. Multipara,Grand multipara )
• More than one fetus (e.g. Twins)
• Too much or too little amniotic fluid (e.g.
  Poly hydramnious, oligohydramnios)
• Abnormal uterine shape (e.g. Arcuate ,septate,
  supseptate) or abnormal growth (e.g Fibroid)
• Placenta previa
• The baby is preterm

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Defintion
Incidence of malpresentation

• Breech 3 in 100 (3)
• Face 1 in 500 (0.5)
• Brow 1 in 2000 (0.02)
• Shoulder 1 in 300 (0.3)
• Compound 1 in 5000 ( 0.05)

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Shoulder Presentation
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Shoulder presentation

• It is a Transverse lie
• in which the long axis of the
• fetus is perpendicular( 900)
• to long axis of mother.
• Shoulder of baby comes in
• the lower segment of uterus(0.5)

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4 position in Shoulder presentation

• Acrimon- anterior(60)
• Left
• Right
• Acrimo- posterior(40)
• Right
• Left
• Acrimo anterior position is more common as the
  concavity of front of fetus fix in convexity of
  maternal spine
• Placenta is posterior in 60 of cases

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Lt
Acrimoanterior Rt Acrimoanterior Rt
Acrimoposterior Lt Acrimoposterior
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Diagnosis

• Abdominal examination,
• the head is usually felt in one iliac fossa or in
  the flank.
• The breech in the other iliac fossa but at a
  higher level
• Fundal level just above umbilicus
• FH sound heard below the umbilicus

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On vaginal examination

• Early in labor
• the cervix is elevated
• lower uterine segment is
• imperfectly filled
• Late in labor
• The cervix is sufficiently dilated We can feel
  scapula, acromion, clavicle, axilla and ribs
• Confirm position If the arm is prolapsed
  and supinated the dorsum points to the back
  and the thumb points to the head.

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Neglected shoulder

• Prolonged labor
• Membrane ruptured
• liquor drained
• Arm may be prolapsed
• Fetus dead or dying
• Lower segment overstretched
• Signs and symptoms of obstructed labor

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Management

• During pregnancy
• A-External cephalic version
• Can be tried up to full term,
• Even early in labour before ROM
• Laxity of the abdominal uterine walls
  makes the procedure easier than in breech
• The fetus will be rotated only 90 degrees.
• B. If fails, do external podalic version. head.

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During labor

• External cephalic version (ECV) is tried with
  intact membranes
• - If succeeded
• Rupture of membranes and application of
  abdominal binder.
• - If failed
• C.S. is the safest for the mother fetus.
• If the membranes are ruptured before full
  cervical dilatations do C.S.

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Management

• In modern practice, persistent transverse lie
  in labor is delivered by caesarean section
  whether the fetus is alive or dead

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Face Presentation
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Face Presentation

• head is hyper extended
• presenting part is face
• - denominator is chin(mentum)
• between glabella chin
• presenting diameter is
• submentobregmatic (9.5cm)

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Types of Face Presentation

• 2ry face (during labor) commen
• The majority of cases of face are secondary to
  occipto-posterior which transformed to mento
  anterior
• Causes are maternal
• 1ry face (during pregnancy )rare
• Causes are fetal

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AETIOLOGY
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In Face presentation- 6 position
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Lt mento-ant
Rt mento-ant
Rt mento-post
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Diagnosis

• The chin serves as the
• referenc point in describing
• the position of the head.
• It is necessary to distinguish
• chin-anterior positions in
• which the chin is anterior in
• relation to the maternal pelvis
• from chin-posterior positions.

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Diagnosis

• On abdominal examination,
• a groove may be felt between
• the occiput and the back.
• On vaginal examination
• Neither the occiput nor the
• sinciput are palpable
• supra-orbital ridges, chin,
• alveolar margin ala nasi
• Confirm presention

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Mechanism of labor in MA

• The head descends with the submento-bregmatic
  diameter (9.5 cm).
• Descent, engagement, increased extension of
  the head
• the chin meets the pelvic floor first and
  rotates forwards 1/8 of a circle.
• With further descent the submental-region
  hinges below the symphysis pubis
• the head is delivered by flexion , followed by
  restitution and external rotation of the chin as
  in vertex presentation.

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Mechanism of labor in MP

• Normal mechanism In 2/3 of cases
• the chin rotates forwards 3/8 of a circle
• and delivered as MA
• Abnormal mechanism (In 1/3 of cases)
• The chin may rotate forwards
• 1/8 circle (deep transverse arrest of the face).
• no rotation(persistent oblique MP).
• The chin rotate backwards 1/8 circle (direct MP)

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Management of Chin-anterior
Cervix fully dilated
Cervix not fully dilated
Allow normal child birth
Augmentation of labour
Slow progress with no signs of obstruction
Descent unsatisfactory
Augmentation of labour
Forceps delivery
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Braw presentation
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• It is a cephalic presentation with the
  head midway between flexion and extension.
• Incidence 1 /2000
• The frontal bone is
• the denominator.

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There are 4 main positions

• - Left fronto-anterior.
• - Right fronto-anterior.
• - Right fronto-posterior.
• - Left fronto-posterior.

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Types Etiology of brow

• Transient brow(2RY)
• During conversion of vertex to face.
• Persistent brow(1RY)
• Extremely rare
• Etiology same as face

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Mechanism of labour

• Transient brow(2RY)
• brow may be converted spontaneously into
  face (by extension) or vertex (by flexion)
  and this followed by spontaneous delivery

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Persistent brow

• There is no mechanism
• for delivery because the
• head descends by the mento
• -vertical diameter (13.5 cm)
• which is longer than any
• of the diameters of the pelvic inlet.
• So, the head become arrested at the pelvic
  inlet ,and labour is obstructed.

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Diagnosis

• Abdominal examination
• the occiput sinciput
• are felt at the same level
• PV examination
• frontal bone, supra-orbital
• ridges and the root of the
• nose are felt.

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Compound Presentation

• Occurs when an extremity (usually an arm less
  commonly lower limb) prolepses alongside the
  presenting part.
• Both the prolapsed arm and the fetal head present
  in the pelvis simultaneously.

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Diagnosis

• Suspect compound presentation when
• Active labor is arrested
• The fetus fail to engage
• The prolapsed extremity is palpated directly

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Management

• Dont manipulate the prolapsed extremity
• In many cases the extremity will spontaneously be
  pulled back and away from the presenting part.
• Spontaneous delivery in 75 of vertex /upper
  extremity presentation
• Do continuous FHR monitoring because of
  associated occult cord prolapse

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• Reduce the extremity if
• Prolapsed extremity prevent descent of fetus
  gently reduce by pushing it upward above the
  pelvic brim and hold it until a contraction
  pushes the head into the pelvis. 
• Do CS if
• Non reassuring FHR trace
• Cord prolapsed
• Failure of labor to progress

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