MALPRESENTATION

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MALPRESENTATION

• MALPOSITION

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LECTURE OVERVIEW

• Abnormal lie, malpresentation and malposition
• Malpresentation and its management
• breech
• face
• brow
• shoulder
• compound

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DEFINITIONS

• Abnormal lie
• where the long axis of the fetus is not lying
  along the long axis of the mother
• LONGITUDINAL (MAY BE EITHER CEPHALIC OR BREECH)
• TRANSVERSE
• OBLIQUE
• UNSTABLE

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DEFINITIONS

• Malpresentation
• where the fetus is lying longitudinally, but
  presents in any manner other than vertex
• BREECH
• FACE
• BROW
• SHOULDER
• COMPOUND
• CORD

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DEFINITIONS

• Malposition
• where the fetus is lying longitudinally and the
  vertex is presenting, but it is not in the OA
  position
• OT (LOT, ROT)
• OP

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DEFINITIONS

• Malpresentation
• where the fetus is lying longitudinally, but
  presents in any manner other than vertex
• BREECH
• FACE
• BROW
• SHOULDER
• COMPOUND
• CORD

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MANAGEMENT OF BREECH PRESENTATION AT TERM

• Management options
• (1) external cephalic version
• (2) elective caesarean section
• (3) trial of vaginal delivery

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EXTERNAL CEPHALIC VERSION

• CONTRAINDICTAIONS
• 3rd trimester bleeding
• uterine anomalies
• ROM, oligohydramnios
• need for CS for other reasons (placenta praevia,
  contracted pelvis, hyperextended head)
• indicated vaginal delivery (fetal death, anomaly
  best delivered as breech)

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EXTERNAL CEPHALIC VERSION

• SUCCESS
• 60-70
• TECHNIQUE
• after 36W
• CTG prior
• attempt to perform forward somersault
• tocolytic
• CTG after (8 bradycardia 5 fetomaternal
  haemorrhage)
• anti D (if Rh negative)

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ELECTIVE CAESAREAN SECTION

• EFW lt2500g gt3500g
• preterm breech
• hyperextended fetal head
• palcenta praevia
• concerns re. fetal well being, including
  oligohydramnios
• footling breech
• 10 risk of cord prolapse
• ?complete breech
• 5 risk of cord prolapse (c.f. 1 with frank
  breech)
• ?all PG breech

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CRITERIA FOR VAGINAL DELIVERY

• Frank or complete breech
• EFW 2500-3500g
• gestational age gt36 weeks
• fetal head must be flexed
• maternal pelvis must be adequate
• judged clinically or by pelvimetry
• no other maternal or fetal indiaction for CS
• experienced obstetrician, anaesthetist and
  paediatrician present at delivery

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FACE PRESENTATION

• Incidence 0.2
• Mechanics of presentation
• Characterized by extreme extension of the fetal
  head so the face (rather than the skull) presents
  to the birth canal
• Aetiology
• any factor that favours extension such as fetal
  goitre, anencephaly
• high maternal parity
• At diagnosis
• 60 mentoanterior
• 15 mentotransverse
• 25 mentoposterior

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BROW PRESENTATION

• Incidence 11400
• Mechanics of presentation
• head is extended such that attitude is halfway
  between flexion (vertex) and hyperextension
  (face)
• usually transitional- when the head is in the
  process of converting from a vertex to a face or
  vice versa
• presenting part is between the facial orbits and
  anterior fontanelle
• supraoccipitomental diameter is presenting
  13.5cm cf 9.5cm for suboccipitobregmatic
  (vertex) or submentobregmatic (face)

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AETIOLOGY

• Fetal
• prematurity, multiple
• Liquor
• polyhydramnios
• Uterine
• anomaly
• Placenta
• praevia
• Pelvis
• contraction, tumour
• Parity
• high maternal parity (80 of cases occur in women
  who are para3 or more)

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MANGEMENT

• Exclude cord prolapse
• occurs in up to 20 of cases
• Otherwise expectant
• mostly doesnt interfere with normal delivery
• vertex-foot try to gently reposition the lower
  extremity
• if arm prolapses in vertex-hand, wait and see if
  it moves as head descends if it converts to
  shoulder presentation, deliver by CS

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SUMMARY

• Abnormal lie, malpresentation, malposition
• Incidence, mechanics, aetiology, diagnosis,
  management of
• BREECH PRESENTATION
• FACE PRESENTATION
• BROW PRESENTATION
• SHOULDER PRESENTATION
• COMPOUND PRESENTATION