Malpresentation

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Malpresentation

• Dr. Abdalla H. Elsadig
• MD

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Definitions

• Presentation
• Is the lowermost part of the fetus occupying
  the lower uterine segment ( cephalic, breech,
  hand, cord etc).
• Malpresentation
• includes all presentations other than
  cephalic.

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Why malpresentation?

• In vertex presentation the presenting part is a
  typical sphere (9.5 X 9.5 cm) this sphere will
  allow
• Production of equal uterine contraction ?
  efficient uterine contractions.
• Production of equal cervical dilatation ? well
  fitting presenting part.
• The membrane remain intact for a long time (6-8
  cm).
• The cord will not prolapse.
• In malpresentation the presenting part is
  irregular, not fitting well to the cervix ?
  complications during labour.

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Breech Presentation

• Incidence at term 3-4, at 32 weeks 15 and at
  28 weeks 20.
• Types of breech
• extended or frank (60-70) the thighs are flexed
  at hip joints and the legs are extended the knee
  joints.
• Complete or flexed (25) The thighs and legs are
  flexed at hip and knee joints
• Incomplete (10) The fetal foot or knee is the
  lowermost presenting part

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Etiology of breech presentation

• Feto-maternal factors
• Preterm delivery.
• Placenta praevia
• Multiple gestation
• Previous history of breech delivery.
• Polyhydramnios/oligohydramnios.

• Preterm delivery (major reason)
• Maternal factors
• Uterine anomalies bicornate
• Pelvic mass fibroids ovarian...
• Anticonvulsant therapy.
• Drug /alcohol abuse.
• Fetal factors
• IUGR/death.
• Congenital anomalies (esp. CNS)
• - anencephaly/hydrocephalus
• - Myelomeningocele.
• - prader-Willi syndrome

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Diagnosis of breech presentation

• Abdominal palpation
• Fetal heart auscultation

• Ultrasound
• Vaginal examination
• Frank breech
• - Ischial tuberosities, the sacrum and anus are
  palpable
• Complete breech
• - Feet are felt along side the buttock.
• Footling
• - foot or knee is presenting

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Management of breech presentation

• Antenatal management
• Fetal an d maternal assessment.
• External cephalic version.
• Breech delivery
• When? (Time of delivery)
• Term/preterm delivery.
• How? (Mode of delivery)
• Vaginal delivery
• Spontaneous breech delivery
• Assisted breech delivery
• Breech extraction
• Caesarean section

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Antenatal management

• External cephalic version
• Benefits 97.5 success rate.
• Indications uncomplicated breech presentation
  after 37 weeks gestation.
• Absolute contraindications
• - multiple pregnancy APH
• - Ruptured membrane.
• - fetal abnormalities.
• - cord around the neck.
• Relative contraindications
• - previous C/S maternal disease.
• - maternal obesity BMI gt 20 of the ideal.
• Risks of ECV
• Procedure of ECV

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Vaginal breech delivery

• Criteria
• Frank or complete breech presentation with
  gestational age gt 36 weeks.
• Estimated fetal weight of 2.5-3.5 kg.
• flexed fetal head. Extended head (due to nuchal
  cord, fundal placenta, neck muscle spasm, uterine
  abnormalities) associated with gt 90 poor
  prognosis.
• Adequate maternal pelvis (Multiparous).
• No other obstetric complications previous C/S,
  PET, diabetes, IUGR,..etc.
• Preferably epidural analgesia.
• Well trained staff and equipped hospital.

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Procedure of breech delivery

• Types of vaginal breech delivery
• Spontaneous breech delivery
• Assisted breech delivery
• Breech extraction

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Procedure of breech delivery

• First stage of labor
• - maternal and fetal
• monitoring
• C/S if failure of progress
• or Fetal distress
• - Anaethesia (epidural).
• - Oxytocin (? No)

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Procedure of breech delivery

• Second stage of labor
• -lithotomy position episiotomy
• Spontaneous up to umbilicus
• Rotation to sacro-anterior.
• pressure on popliteal fossa.
• Cord is brought down.
• Allow fetus to hang till to
• see posterior scapular
• Deliver anterior schoulder or
• Lovsets manoevre.

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Procedure of breech delivery
Delivery of posterior arm
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Procedure of breech delivery
Delivery of the head - Mauriceau-Smellie-Veit mane
uver
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Procedure of breech delivery
Delivery of the head Forceps delivery
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Complications of breech delivery

• Fetal complications
• Intracranial haemorrhage
• hypopiturarism.
• Medullary coning
• spinal cord severance.
• Brachial plexus injury
• fracture of long bone
• rupture of internal organs
• amage to male genitalia .
• Damage to mouth and pharynx.

• Occipital diastasis impaction of occipital bone
  over pubic bone in second stage ? separation of
  occipital bone , cerebellum damage, brain tissue
  herniation through foramen magnum, stillbirth or
  ataxic cerebral palsy.
• Maternal complications
• Soft tissue injuries
• Haemorrhage.
• infections

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• A real Slides For vaginal Breech Delivery

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No action
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No action
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episiotomy
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episiotomy
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Perineum support
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Buttocks delivery
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Buttocks delivery
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Legs delivery
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Let baby to hang on weight
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Anterior arm delivery
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posterior arm delivery
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Burn-Marshal manoeuvre
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Burn-Marshal manoeuvre
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Burn-Marshal manoeuvre
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Third stage of labour