Malpresentation:-

كلية الطب ? جامعة بابل المرحلة الرابعة
د-نسرين مالك
Obstetrics

Malpresentation:-

Presentation refers to the part of the fetus that is lowermost within the maternal pelvis.
Malpresentation is any presentation other than the vertex and therefore includes brow , face, breech ,shoulder, compound presentations and cord presentation.
Malpresentation occurs in 3–4 per cent of term pregnancies, but is more common at earlier gestations.
Malpresentations are associated with maternal and fetal morbidity and mortality.
Maternal morbidity is related to the surgical and anesthetic risks related to operative delivery, malpresentations can also result in obstructed labour with its risks of tissue necrosis and subsequent fistula formation or uterine rupture, sepsis and death.
Intrapartum fetal risks of malpresentation include hypoxia from prolonged labour or cord prolapse.

Face presentation:- This malpresentation occurs in about 1:500 labours and is due to complete extension of the fetal head .In the majority of cases, the cause for the extension is unknown, although it is frequently attributed to excessive tone of the extensor muscles of the fetal neck. Rarely, extension may be due to a fetal anomaly such as a thyroid tumour.

Aetiology:-
1-Excessive tone of the extensor muscles of the neck, or musculoskeletal anomalies.
2- Most face presentation are secondary to occiput –posterior position.
3- Fetal goiter. 7- Prematurity.
4- Anencephaly. 8- Placenta praevia.
5-Cord around the neck. 9- Uterine anomalies.
6- Polyhydramnios. 10-Unknown causes.
Clinical findings:-
Abdominal palpation reveals a deep depression between the anterior shoulder and the fetal head in which no fetal part can be felt. The possibility of face presentation can be suspected on abdominal examination if the prominence of the head is palpable more prominently at higher level on the opposite side of the fetal spine. However, the diagnosis is usually made as labour advances on vaginal examination. The landmarks are the mandible, mouth, nose, malar and orbital ridges.
Care should be taken to avoid damage to the eyes on examination. Difficulties may be encountered in recognizing the presentation when the membranes are intact especially if the presenting part is high or in the presence facial oedema as this is make the distinction between a face and breech presentation difficult and ultrasound should be used if there is any doubt. Delay in the first or second stage of labour can also occur.

Mechanism of labour:-
The presenting diameter is the submento-bregmatic, which measures 9.5 cm, and is approximately the same in dimension as the suboccipito-bregmatic (vertex) presentation.
Despite this, engagement of the fetal head is late and progress in labour is frequently slow, possibly
because the facial bones do not mould, and also poor thrust between the body and head of the fetus.
The mechanism of labour has some similarity to that of the vertex. The engagement occur in transverse diameter, the vast majority it rotates forward to be in the mento-anterior position with the chin behind the symphysis pubis.The presenting lateral(biparietal 9.5 cm) and antero-posterior ( submento-bregmatic 9.5 cm) diameters are conductive for vaginal delivery. Descend is possible posteriorly in the pelvis when the position is mento-anterior because of large space in the lateral sacral area.
The head is born with chin emerging under the pubic arch followed by the forehead over the perineum and the head being delivered by flexion as it completed by delivery of the occiput.
If the face rotates posteriorly (mento-posterior position), although the diameters are the same as mento-anterior , the lateral dimensions of the frontal bones are large and do not permit descent behind the narrow retropubic arch and. delivery is impossible hence C\S is advisable.

Management:-
? Ultrasound examination should be performed to exclude fetal or pelvic abnormality that may preclude vaginal delivery.
? Vaginal delivery is possible with the mento-anterior position, but not for mento-posterior. However, mento-posterior position may rotate during the second stage to mento-anterior.
? Following diagnosis in the first stage of labour, the mother should be fully informed of all the possible risks. At the time of diagnosis, facial oedema and bruising may have already occurred. And the recognition of face presentation may delayed untill the time when failure of labour to progress is diagnosed.
? Although augmentation and oxytocin has been used, it is generally not advised, and lack of progress should usually prompt delivery by caesarean section and also if there is any concern about fetal condition.
? In late second stage of labour, with the face at the outlet in mento-anterior or lateral position, outlet forceps delivery can be carried out by skilled person if the spontaneous delivery is not forthcoming.
? Episiotomy is necessary when the occiput distend the valve.
? The vacuum delivery is contraindicated .
?The risks to the fetus are that of facial soft tissue trauma which may persist for several days and can cause feeding difficulties.
?The maternal risks are perineal injury, sphincter damage and second stage Caesarean section.

Brow presentation:-
This arises when there is less extreme extension of the fetal head than that with a face presentation. It
can be considered a midway position between vertex and face. It is the least common malpresentation, occurring in 1:2000 labours.
The causes of this are similar to those of face presentation, although some brow presentations arise as a result of exaggerated extension associated with occipito-posterior position. The presenting diameter is the mento-vertical (measuring 13 cm).
This is incompatible with a vaginal delivery. It is diagnosed in labour by palpating the anterior fontanelle, supra-orbital ridges and nose on vaginal examination


Management:-
? Diagnosis in the early first stage may warrant expectant management for a short time (2–3 hours) as the brow may flex into a vertex, or deflex to a face presentation and thus become amenable to vaginal delivery .
? Augmentation with syntocinon has been described but is not advised as this could result in uterine rupture.
? Diagnosis is often made in the late first or second stage of labour when caesarean delivery is advised. The mid pelvic diameters are 12 × 12 cm and therefore the 13 cm brow will not usually
be able to pass the mid pelvis.
? The mento-vertical dimension may be smaller in a preterm fetus, thus allowing vaginal delivery. However, Caesarean should still be considered, especially in the context of failure to progress because of the risk of cervical cord or intracranial damage.
?In cases of intrauterine death and in those with lethal malformation in extreme preterm period, where injury to the fetus is not concern ,labour may be allowed if there is good progress in anticipation of vaginal delivery.

Complications:- The complications of brow presentation in labour include cord prolapse ,and rare incidence of uterine rupture in neglected cases.

Shoulder presentation
This is reported as occurring in 1:300 pregnancies at term, but few of these women are undiagnosed until labour.Is more common without any cause due to the laxity of the uterus 90?.
However, there are known association and they are:-
1-Transverse or oblique lie. 2-Prematurity. 3-Congenital fetal anomalies.
4- Polyhydrammnios. 5- Placenta praevia, 6-Fibroid, pelvic tumour, or uterine anomalies.
7-High parity.
Delay in making the diagnosis there are risks of cord prolapse and uterine rupture. Delivery should be done by Caesarean section.



Compound presentation:-
Compound presentation refers to more than one fetal part presenting simultaneously. like cases of cephalic presentation where one or more limbs lie along side and presented with the head, and also breech presentation, where one or both arms or hands present with breech.
All are associated with prematurity, multiple pregnancy and prior intrauterine death. it can occur in an unstable lie in labour or at the time of prelabour rupture of membranes.

Presentation of a hand with the vertex accounts for the majority of the cases. Next in frequency are the foot presenting with the head, or the breech with an arm and the least common is simultaneous presentation of arm, foot and vertex.
Diagnosis is usually not difficult once the membranes have ruptured, and this occurs prematurely in
a third of cases.



Management:-Expectant treatment is chosen in case of compound presentation involving a limb alongside the vertex ,which often resolves and may lead to vaginal delivery if progress is satisfactory.
In most cases, the extremity of the limb will recede as the presenting part descend. Replacement of the limb is rarely necessary.
When the arm appears to rise into the uterus with a contraction this is a favorable sign, .
Active treatment by Caesarean section is required in cases complicated by cord prolapsed or if there is delay in the first or second stage of labour.
All other compound presentations delivery is by Caesarean section to avoid uterine rupture.



Cord presentation:- presence of the umbilical cord between the presenting fetal part and fetal membranes. In this case, the cord has not passed the opening of the cervix. In cord presentation, the membranes are not yet ruptured.

Cord prolapse:- describes the cord descending through the cervix into the vagina in the presence of ruptured membranes.

Classification:- There are two types of umbilical cord prolapse that can occur:-

?Overt umbilical cord prolapse: descent of the umbilical cord and past the presenting fetal part. In this case, the cord pass through the cervix and into or beyond the vagina. Overt umbilical cord prolapse requires rupture of membranes. This is the most common type of cord prolapse.

?Occult umbilical prolapse: descent of the umbilical cord alongside the presenting fetal part, but has not advanced past the presenting fetal part. Occult umbilical prolapse can occur with both intact or ruptured membranes.
There are two major categories of risk factors that predisposing to umbilical cord prolapse ,these are; spontaneous and iatrogenic ( those that result from medical intervention):-
• Spontaneous factors:-
o a high fetal head or fetal malpresentation: breech( especially footling breech),abnormal fetal lie.
o polyhydramnios.
o prematurity.
o low birth weight.
o .multiple pregnancy.
o spontaneous rupture of membranes.
• Iatrogenic factors:-
o artificial rupture of membranes(stabilizing induction of labour).
o placement of internal monitors (for example, internal scalp electrode or intrauterine pressure catheter)
o manual rotation of fetal head .
o external cephalic version or internal podalic version.

Cord prolapse

Historically, the incidence of cord presentation/cord prolapse is 1/200–300 deliveries.
More recent studies suggest rates of 0.1–0.6 per cent of all births and just above 1 per cent for breech
presentations.
Diagnosis:-
?Cord presentation :- the diagnosis is made by feeling the pulsation of the cord through the intact membranes. The presence of a ‘high’ presenting part (head or breech) in early labour should prompt ultrasound (doppler U\S), which may detect the presence of a cord presentation.

?Overt cord prolaps:- The cord is palpated directly by the fingers and its pulsation can be felt if the fetus is alive. Cord pulsation may be cease during uterine contraction which, however, returns after the contraction passes off.

?Occult cord prolapsed:- is difficult to diagnose. The possibility should be suspected if there is persistence of variable deceleration of fetal heart rate pattern detected on continuous electronic fetal heart monitoring.

Management:-
?Cord presentation necessitates urgent caesarean delivery as rupture of membranes may precipitate cord prolapsed.

?Cord prolapse is an emergency, and delivery should be expedited. Fetal hypoxia occurs secondary to pressure of the presenting part and bony pelvis on the cord occluding fetal placental circulation. In addition, prolapse of the cord beyond the introitus causes arterial spasm in case of low temperature.

Abnormal cardiotocography, such as persistent fetal bradycardia or recurrent decelerations, should raise the possibility of cord prolapse and a vaginal examination should take place to investigate this as a cause.

Management of cord prolapse is by:-
1-Left lateral with Trendelenberg position, 100? oxygen by face mask. The cord should be replaced in the vagina with minimal handling, and the presenting part elevated to avoid compression of the cord. This may involve simultaneous manual displacement of the presenting part, maternal head down tilt or maternal knee to chest position. The use of an indwelling catheter has also been described to fill the maternal bladder and again elevate the fetal presenting part from the cord. This can provide valuable time if delivery is unavoidably detained.A 16-gauge Foley catheter is placed in the bladder and filled with 500–700 ml saline before being clamped. Just before delivery, the clamp is released.
Immediate plans for delivery should occur in the presence of a viable fetus.

2- Discontinue oxytocin if present, and continuous fetal monitoring should be in place while delivery is expedited. Ultrasound assessment of the fetal heart may be necessary as audible heart tones and cord pulsations may cease prior to delivery even though the fetus remains viable.

3- Terbutaline (0.25 mg subcutaneously) should also be considered as a tocolytic to minimize cord compression from uterine activity .

4- If the fetus is viable , cephalic , and the cervix is fully dilated ,consider ventouse or forceps if easy delivery anticipated , but if not fully dilated or vaginal delivery deemed inappropriate or unsuccessful so management as the following:-
?If fetal hart is normal ,make arrangement for emergency Caesarean section ( urgency grade II).
? If fetal heart rate is abnormal, prepare for emergency Caesarean section ( urgency grade I).
Remembering to unclamp catheter and drain bladder before surgery.

5- If the fetus is not viable ,await spontaneous delivery, unless there is contraindication as in cases of increase risk of uterine rupture like previous 2 or more C\S, obstructed labour as in cephal-opelvic disproportion and others, in these cases do Caesarean section.













كلية الطب ?جامعة بابل المرحلة الرابعة
د-نسرين مالك
Obstetrics


Abnormal lie:-Transverse lie, oblique lie and unstable lie :-

A transverse lie occurs when the fetal long axis lies perpendicular to that of the maternal long axis in which the fetus is positioned 90° with respect to the mother s dorsal column.
An oblique lie occurs when the long axis of the fetal body crosses the long axis of the maternal body at an angle close to 45 degrees(in which the fetus may be in transition from a vertical to a transverse lie).
Unstable lie is alternating between transverse, oblique and longitudinal, it is important to think of possible uterine or fetal causes. A fetus can be in an unstable or variable lie when the head is completely unengaged and floating. This situation is seen mostly in cases of severe polyhydramnios and prematurity.

In transverse lie, and oblique lie the fetal back is usually anterior with the head most often to mother s left, the fetal attitude is one of flexion. Thought the dorso-posterior position are less common they inevitably cause fetal extension with greater risk of arm prolapsed and associated twisting of the fetal spine.




Transverse lie: A Dorso-anterior B Dorso-posterior


Oblique lie

Any woman presenting at term with a transverse, oblique , or unstable lie is at potential risk of cord prolapse following spontaneous rupture of the membranes, and prolapsed of the hand, foot or shoulder presentation once in labour. In most cases, the woman is multiparous with a lax uterus and abdominal wall musculature, and gentle version of the baby’s head in the clinic or on the ward will restore the presentation to cephalic.

Incidence :-An incidence of 1/320 is recorded in historical studies.
Aetiology:-
1-There is an association with progressive multiparity which is likely to be related to progressive laxity of the uterine musculature with each pregnancy.
2-The presence of polyhydramnios gives greater freedom of fetal movement and can predispose to these abnormal lies.
3-Placenta praevia may act as a physical obstruction to fetal engagement, as may any pelvic tumour, significant uterine anomaly or, more rarely, a contracted maternal pelvis.
4-Hydrocephalus and fetal tumours of the neck or sacrum may prevent engagement of the fetal head in the pelvis.
5-Fetal neuromuscular dysfunction may impede engagement secondary to reduced fetal movement.
Clinical findings:-The diagnosis of transverse or oblique lie might be suspected by abdominal inspection: the abdomen often appears asymmetrical. The SFH may be less than expected, and on palpation the fetal head or buttocks may be in the iliac fossa. Palpation over the pelvic brim will reveal an ‘empty’ pelvis.
The absence of a fetal pole in the pelvis on abdominal or vaginal examination, either antenatally or in labour, should raise the likelihood of an unstable/non-longitudinal lie (transverse lie, and oblique lie).
Management:-
1- In case of transverse lie , clinical findings should be confirmed by ultrasound examination .This should also look for fetal anomaly, measure liquor volume and check placental site. The presence of pelvic tumours or congenital uterine anomalies may be difficult to identify in late pregnancy.
Following exclusion of placenta praevia, vaginal examination is usually sufficient to exclude significant pelvic deformity or space-occupying lesion. X-ray pelvimetry does not add additional useful information to aid management.
2-In the presence of obstructive fetal or uterine pathology that precludes vaginal delivery: Caesarean section should be planned at the appropriate gestation. This may need to be a classical caesarean depending on the extent of the anomaly, and the woman should be counseled regarding that possibility. The risk of cord prolapse in the event of contractions or rupture of membranes should also be discussed and women advised to attend hospital promptly if these occur.
3- Even in the absence of an obstructive cause, inpatient management should be recommended
from 37 weeks because of the risk of cord prolapse, to enable rapid intervention if required .
In the majority of cases, spontaneous version to longitudinal lie will occur prior to membrane rupture or labour onset.
? Conservative management involves daily review and discharge home after the lie stabilizing longitudinally for 48 hours.
? Active management involves attempting an external cephalic version( ECV),with discharge home if the lie remains longitudinal. However, recent RCOG guidelines suggest that ECV should only be done with immediate induction ‘stabilizing induction’.Stabilizing induction requires a favorable cervix and immediate facilities for caesarean section in the event of a cord prolapse. ECV should not be attempted if there is advance laboure,efficient uterine contraction or ruptured membranes
In the case of the membranes rupture and the fetus is still in the transverse lie,CS should be performed to avoid injury to the fetus or the uterus.
A woman with an unstable lie at term should be admitted to the antenatal ward. The normal plan would be to deliver by Caesarean section if the presentation is not corrected to cephalic in early labour or if spontaneous rupture of the membranes occurs. In a multiparous woman, an unstable lie will often correct itself in early labour (as long as the membranes are intact). ECV can be attempted but with immediate recourse to Caesarean section if unsuccessful..
4- If the fetal lie remain non-longitudinal post term, an elective caesarean section should be offered.
5- Internal podalic version:- is done in case of delivery of second twin.
6-Labour and spontaneous vaginal delivery is possible in extreme preterm, macerated dead fetuses.