Submitted to: Submitted by:

Mrs. Indira Jothi Mrs. Suneetha Prabhu

Lecturer II year M. Sc Nursing

Canara College of Nursing C.C.O.N

Mal-position and mal-presentations

Relationship of fetus to Uterus and Pelvis

Relationship determines which part of the fetus will enter the pelvic brim first and governs the mechanism by which
the fetus will pass through the birth canal

The terms are:

Lie Presentation Position

Attitude Denominator Presenting Part

Lie: Lie is the relation of the long axis of the fetus to the long axis of the uterus

Normal : Longitudinal

Abnormal: Transverse/oblique

Attitude: Attitude is the relation of the fetal limbs and head to its trunk

A: Normal : Flexion

B: Moderate flexion or Military attitude

C: Marked Extension( Brow)

D: Hyperextension (Face)

Presentation: Presentation refers to the part of the fetus which lies at the pelvic brim or in the lower pole of the
uterus.

There are five presentations: Vertex, breech, shoulder, face, brow

The Denominator: The Denominator is the part of the presentation that indicates or determines the position of the
fetus

Vertex presentation : occiput

Breech presentation: Sacrum

Face presentation : Mentum

Shoulder : Acromion process

Brow : frontal bone

Position: Position is the relation of the denominator to six areas of the pelvic brim .

The areas of the brim are:

Right posterior Left posterior

Right Lateral Left Lateral

Right anterior Left anterior

Presenting part: The presenting part is the part that lies over the cervical os during labour and on which the caput
forms

Occipito posterior position

In a vertex presentation where the occiput is placed posteriorly over the sacro iliac joint or directly over the sacrum, it
is called occipito posterior position

When the Occiput is placed over the right sacro-iliac joint, the position is called right occipito-posterior, traditionally
called 3rd position of the vertex and when placed over the left sacro iliac joint, is called Left occipito –posterior
traditionally called 4th position of the vertex and when it points towards the sacrum, is called direct occipito posterior.

Incidence: At the onset of labour, the incidence is about 10% of all the vertex presentations. Right occipito posterior
position is 5 times more common than the left occipito posterior.

Causes

Exact cause not known: The factors responsible are:

● Shape of the pelvic inlet (mostly associated with android pelvis or anthropoid pelvis)

● Fetal factors: Marked deflexion of the fetal head

The causes for deflexion are

● High pelvic inclination

● Attachment of placenta on the anterior wall of the uterus

● Primary brachy-cephaly

● uterine factors : abnormal uterine contraction

Diagnosis

Abdominal examination

Inspection: Abdomen looks flat below the umbilicus

Palpation

1. Limbs are felt on both sides of the midline

2. Back may be difficult to locate

3. Prominent sincipital end is directed forward. Both occiput and sinciput are at the same level

4. Fetal heart sounds are heard at the flanks

Vaginal examination

Findings in early labour

 Elongated bag of membranes

 Sagital suture in oblique diameter

  Posterior fontanelle is felt near sacroiliac joint

 Anterior fontanelle felt easily due to deflexion of the head

Findings in late labour

 Difficult to assess as caput forms

 Ear to be located

Mechanism of labour

Engagement of head: Right oblique diameter in ROP, Left oblique diameter in LOP.

Engaging Diameter: Biparietal (9.5 cm) in transverse diameter and A.P diameter is sub occipito frontal (10 cm)or
occipito-frontal(11.5cm)

Favourable condition (90%)

 Flexion: Good uterine contractions result in good flexion of the head. Descent occurs until the head reaches
the pelvic floor.

 Internal rotation of the head: As the occiput is the leading part, it rotates 3/8 th of a circle anteriorly to lie
behind the symphysis pubis. As the neck cannot sustain such amount of tortion, the shoulders rotate about
2/8th of a circle to occupy the right oblique diameter in ROP and the left oblique in LOP with 1/8 th of a circle
torsion of teh neck still left behind.

 Further descent: Further descent and delivery of the head occurs like that of occipito anterior position.

 Restitution: There is movement of restitution to the extent of 1/8 th of a circle in the opposite direction of
internal rotation of the head.

 External Rotation: The external rotation of teh head occurs through 1/8 th of a circle in the same direction of
restitution as the shoulders rotate from the oblique to anterior-posterior diameter of teh pelvis.

 Birth of the shoulders and trunk: The process of expulsion is the same as that of occipito-anterior

Unfavourable condition (Non-rotation or malrotation) -10%

Causes: Deflexion of head

Weak uterine contraction

Faulty shape of the pelvis such as weak pelvic floor muscles

Big baby

Incomplete forward rotation: occiput rotates 1/8th of circle and sagital suture comes to lie in the bispinous diameter.
Thereafter further anterior rotation is unlikely and arrest in the position is called deep transverse arrest

Non- rotation: Both the sinciput and the occiput touches the pelvic floor simultaneously due to moderate deflexion
of the head resulting in non rotation of the occiput. The sagital suture lies in the oblique diameter. Further mechanism
is unlikely and the condition is called oblique posterior arrest.

Malrotation: In extreme deflexion, the sinciput touches the pelvic floor first resulting in anterior rotation of the
sinciput to 1/8th of the circle and putting the occiput to the sacral hollow. This is in true sense, persistent occipito-
posterior position.

In favourable circumstances with an average size baby, good uterine contractions and an adequate pelvis sponatneous
delivery may occur “face to pubis”
Unfavourable condition, when the arrest occurs, it is called “occipito sacral arrest”

Mechanism of “face to pubis” delivery

● Further descent occurs until the root of the nose hinges under the symphysis pubis

● Flexion occurs -releasing successively the brow, vertex and occiput out of the stretched perineum and
then face is born by extension

● Restitution: The head moves towards mothers left thigh in R.O.P and right thigh in L.O.P

● External rotation: the occiput further rotates to the same direction of restitution to 1/8 th of a circle
planning finally the face looking directly towards the left thigh in R.O.P and the right thigh in L.O.P

● Lateral flexion of the body

Course of labour

The average duration of both first and second stage of the labour is increased

First stage:

 Engagement is delayed due to persistent deflection of the head.

 Membrane status: Early rupture and drainage of liquor

 Uterine contraction: Abnormal uterine contraction .with slow dilatation of the cervix.

Second stage:

Delayed due to long internal rotation or mal rotation with at times, arrest of the head

Third stage:

There is increased incidence of postpartum haemorrhage and trauma of the genital tract.

Mode of delivery

Long anterior rotation of the occiput: Spontaneous or aided anterior vaginally delivery occurs.

Short posterior rotation: Spontaneous or aided anterior vaginally delivery occurs.

Non rotation or short anterior rotation: Spontaneous vaginal delivery is unlikely except in favourable circumstances.

Management of labour:

Principles:

 Early diagnosis

 Strict vigilance with watchful expectancy hoping for descent and anterior rotation of the occiput

 Judicious and timely interference

Early caesarean section: Pelvic inadequacy, unfavourable configuration along with obstetric complication such as
pre-eclampsia, post caesarean pregnancy, big baby usually need caesarean section.

First stage: In otherwise uncomplicated cases, the labour is allowed to proceed in a manner similar to normal labour.

Second stage: In majority anterior rotation of the occiput is completed and the delivery is either spontaneous or can be
accomplished by low forceps or ventous.
Third stage: Prophylactic ergometrine 0.25mg with the delivery of anterior shoulder to be given. Following vaginal
operative delivery meticulous inspection of the cervix and lower genital tract should be made to detect any injury.

Arrested occipito posterior position

If there is failure to progress inspite of good uterine contractions for about ½-1 hour after full dilatation of the cervix,
interference is indicated.

I. Arrest in occipito transverse or oblique O.P position:

1). Ventous: It is suitable in cases where the pelvis is adequate and the non rotation of the occiput is due to either to
week contraction or to lack of tone of pelvic floor muscles.

2). Alternative methods:

 Manual rotation followed by forceps extraction: The objectives are first to rotate the head manually until the
occiput is placed behind the symphysis pubis and secondly in that position forceps blades are applied.

 Forceps rotation and extraction: In the hands of experts, forceps rotation followed by extraction can be
achieved by using Kielland forceps.

 Caesarean section

 Craniotomy: The dead baby should be delivered by craniotomy.

II). Occipito sacral arrest: If the head is engaged and the occiput descends below the ischial spines, forceps
application in unrotated head followed by extraction as face to pubis is an effective procedure. Liberal mediolateral
episiotomy should be done. If the occiput remains at or above the level of ischial spines, caesarean section should be
considered.

Deep transverse arrest

The head is deep into the cavity, the sagital suture is placed in the transverse bispinous diameter and there is no
progress in descent of the head even after ½-1 hour following full dilatation of the cervix.

Causes:

 Faulty pelvic architecture such as prominent ischial spine, flat sacrum and convergent side walls

 Deflexion of the head

 Weak uterine contraction

 Laxity of the pelvic floor muscles

Diagnosis:

a) The head is engaged

b) The sagital sutures lies in the transverse bispinous diameter

c) Anterior fontanelle is palpable

d) Faulty pelvic architecture may be detected

Management:

Vaginal delivery is found safe. Any of the methods may be employed-

 Ventous
  Manual rotation and application of forceps

 Forceps rotation and delivery with Kielland forceps

 Vaginal delivery is not safe-Caesarean section

 Craniotomy in dead baby

Manual rotation:

The manual rotation can be accomplished with whole hand method or with half hand method.

Steps: The patient is put under GA and in lithotomy position. Full asepsis is maintained. Bladder is catheterized.
Vaginal examination is done to identify the direction of the occiput.

Whole hand method: Whole of the hand is introduced inside the vagina for rotation.

Step 1: Gripping of the hand: In ROP or ROT the left hand and in LOP or LOT the right hand is usually used. The
corresponding hand is introduced into the vagina in a cone shaped manner after separating the labia by two fingers of
the other hand. In occipito transverse position, the four fingers are pushed in the sacral hollow to be placed over the
posterior parietal bone and the thumb is placed over the anterior parietal bone. In oblique posterior position, the 4
fingers of partially supinated hand are placed over the occiput and the thumb is placed over the sinciput.

Step2: Rotation of the head: By a movement of pronation of the hand, the head is rotated to bring the occiput anterior
along the shortest route. Simultaneously the back of the fetus is rotated by the external hand from the flank to the
midline.

In the alternative method the four fingers of the pronated right hand are placed over the sinciput and the thumb over
the occiput in ROP. The head is rotated by supination movement of the hand.

Step3: Application of the forceps: Following rotation when the right hand is placed on the left side of the pelvis, left
blade of the forceps is introduced. When the left hand is used, it is placed on the right side of the pelvis after rotation,
as such the right blade is to be introduced first and the left blade is then to be introduced underneath the right blade.

Half hand method: In this rotation, the four fingers and not the thumb are introduced into the vagina.

Advantages over the whole hand method: less space is required, less chance of displacement of the head.

Steps: The rotation is done only using the right hand. The four fingers are introduced into the vagina and tangential
pressure is applied on the head at the level of level of diameter of engagement. Thus the pressure is applied on the side
and the parietal eminence of the head. In ROP or ROT positions, the fingers are placed anterior to the head and the
pressure is applied by the ulnar border of the hand. In LOP or LOT positions, the fingers are placed posteriorly and the
pressure is applied by the radial border of the hand. The force is applied intermittently till the occiput is placed behind
the symphysis pubis.

Malpresentations

Etiological Factors

1. Maternal and Uterine factors: Contracted pelvis, pendulous maternal abdomen, neoplasms, uterine anomalies,
abnormalities of placental site or location, high parity

2. Fetal factors: Large baby, errors in fetal polarity, abnormal internal rotation, fetal attitude, multiple pregnancy,
fetal anomalies, Polyhydramnios, prematurity

3. Placenta and membranes: Placenta praevia, cornual implantation, premature rupture of membranes
Effects of Malpresentations

Effects on labour

a) The incidence of fetopelvic disproportion is high

b) Inefficient uterine action

c) Prolonged labour

d) Pathologic retraction ring

e) The cervix dilates slowly and incompletely

f) The presenting part stays high

g) Premature rupture of the membranes occurs often

h) The need for operative delivery is increased

Effects on the mother

a. Maternal exhaustion

b. More chance for laceration

c. Bleeding is more profuse

d. Greater incidence of infection

e. Paresis of bowel and bladder

Effects on the fetus

 Difficult for the fetus to pass the pelvis

 Greater incidence of anoxia, brain damage, asphyxia and IUD

 Higher incidence of operative delivery

 Prolapse of umbilical cord more common

Face presentation

In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact against the
upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between
the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during a vaginal
examination. The mentum can present in any position relative to the maternal pelvis. If the mentum presents in the left
anterior quadrant of the maternal pelvis, it is designated as left mentum anterior (LMA).

Incidence

Face presentation occurs in 1 of every 250-690 live births, averaging about 0.2% or 1 in 500 live births overall.

Etiology

The cause is not clear in all the cases. The following are the factors which are often associated.

Maternal: Multiparity with pendulous abdomen, Lateral obliquity of the uterus specially if it is directed to the side
towards which the occiput lies, contracted pelvis
Fetal:

1. Congentital malformation: Anencephaly, congenital goiter, dolicocephalic head with long anterio-posterior
diameter, congenital brachocele

2. Twist of the cord several times round the neck

3. Increased tone of the extensor group of neck muscle

Position

There are 4 positions according to the relation of the chin to the left and right sacroiliac joints or to the right and left
ilio-pubic eminences, Right mento-posterior, left mento-posterior, left mento-anterior, right mento-anterior.

Mechanism of labour

Mento-anterior: The principal movements are like those of corresponding occipito-anterior position. The exceptions
are increasing extension instead of flexion and delivery by flexion instead of extension of the head.

 Engagement: The diameter of engagement is the oblique diameter-right in LMA, left in RMA with the
mentum related to one iliopubic eminence and the glabella to the opposite sacro-iliac joint. The engaging
diameter of the is submento-bregmatic 9.5cm in fully extended head or submento-vertical 11.5cm in partially
extended head.Descent with increasing extension occurs till the chin touches the pelvic floor.

 Internal rotation: Internal rotation of the chin occurs through 1/8 th of a circle anteriorly placing the mentum
behind the symphysis pubis. Further descent occurs till the submentum hinges under the pubic arch.

 Delivery of the head: The head is born by flexion. Delivering the chin, face, brow, vertex and lastly the
occiput.Restitution occurs through 1/8 th of a circle opposite to the direction of internal rotation. External
rotation occurs further 1/8th of a circle to the same side of restitution. This follows delivery of anterior
shoulder followed by the posterior shoulder and the rest of the trunk by lateral flexion.

Mento posterior: The cardinal movements in the mechanism of mento-posterior positions are like those of occipito-
posterior position. The salient differentiating features are

 In the mento-posterior position, anterior rotation of the mentum occurs in only 20-30% cases.

 In the rest, incomplete rotation or shot posterior rotation of the mentum occurs.

Diagnosis

• This is generally made on vaginal examination in advanced labour. Other diagnostic clues include:

• S-shaped fetal spine

• Ovoid shaped uterus without fullness in the flanks

• A deep groove is palpated between the back and occiput

• The diagnosis of face presentation can be made clinically by Leopold maneuvers and/or vaginal examination
or radiographically by ultrasound.

• During Leopold maneuvers, the cephalic prominence is on the same side as the fetal back with an indentation
between them, leading the observer to palpate a curvature from the fetal sacrum along the back to the neck
and head. Diagnosis is most commonly made by vaginal examination during labor, when palpation of the
distinct facial features of the mouth, nose, orbital ridges, and malar bones are encountered.

Management
 • exclude: foetal anomaly, contracted pelvis

• check fetal size

Mento anterior:

 First stage: Careful assessment, monitoring is done, In uncomplicated cases , a wait and watch policy is
adopted. Labour is conducted in the usual procedure and the special instructions, as laid down in occipito-
posterior positions are to be followed.

 Second stage: Episiotomy usually required if vaginal delivery. In case of delay, forceps delivery is done.

Mento posterior:

 First stage: in uncomplicated cases, normal vaginal delivery is done.

 Second stage: If anterior rotation of the chin occurs, spontaneous or forceps delivery with episiotomy is all
that is needed.

In incomplete or malrotation:

Caesarean section is done or manual rotation of the chin anteriorly followed by immediate forceps extraction is rarely
done.

GENERAL MANAGEMENT

 Make a rapid evaluation of the general condition of the woman including vital signs (pulse, blood pressure,
respiration, temperature).

 Assess fetal condition:

 Listen to the fetal heart rate immediately after a contraction:

 Count the fetal heart rate for a full minute at least once every 30 minutes during the active phase and every 5
minutes during the second stage;

 If there are fetal heart rate abnormalities (less than 100 or more than 180 beats per minute), suspect fetal
distress.

 If the membranes have ruptured, note the colour of the draining amniotic fluid:

 Presence of thick meconium indicates the need for close monitoring and possible intervention for management
of fetal distress;

 Provide encouragement and supportive care.

 Review progress of labour using a partograph.

Note: Observe the woman closely. Malpresentations increase the risk for uterine rupture because of the potential
for obstructed labour.

Breech presentation
Breech presentation is a longitudinal lie with the variation in polarity where the podalic pole is in the pelvic brim and
the denominator is the sacrum

Incidence

Incidence is 3-4 % of pregnancies. Prior to 28 weeks the incidence is about 25 %. 15 % of the babies presenting the
breech when labour has begun are preterm,three times the overall rate of preterm labour

Etiology

Maternal:

 Uterine relaxation associated with high parity

 Polyhydramnios

 Oligohydromnios

 Uterine anomalies

 Contracted pelvis

Placental: Implantation of the placenta in either cornual fundal region tends to promote breech presentation

Fetal :

● Multiple pregnancy

● Hydrocephaly

● Anencephaly

● Fetal anaomaly: Trisomy disorders where there is alteration of fetal muscular tone and mobility

● Intrauterine death.

● Short cord

Varieties of breech

There are two main categories of breech births:

Complete breech - the baby's hips and knees are flexed so that the baby is sitting cross legged, with feet beside the
bottom.

Incomplete: This is due to varying degree of extension of thigh or legs at the podalic pole.

Three varieties are possible

Frank breech or breech with extended legs – the thighs 65-70% of breech babies are in the frank breech position are
flexed on the trunk and the legs are extended at the knee joints. The presenting part consists of two buttocks and
external genitalia only.

Footling presentation: Both the thighs and the legs are flexed, bringing the knees down to present at the brim.

Knee presentation: Thighs are extended but the knees are flexed , bringing the knees down to present at teh brim.

Diagnosis
Complete breech

Per abdomen

fundal grip: Head-suggested by hard globular mass, head is ballotable

Lateral grip: Fetal back is to one side and limbs to another

Pelvic grip: Breech- suggested by soft, broad and irregular mass

FHS: Usually located at a higher level above umbilicus

Per vaginal Examination

During Pregnancy: Soft and irregular parts are felt through the fornix

During labour: Palpation of the ischial tuberosities, sacrum and the feet by the sides of the buttocks , foot felt is
identified by the prominence of the heel and lesser mobility of great toe.

Frank breech

Per abdomen: Head-suggested by hard globular mass. Irregular limbs felt at side of head, head is non – ballotable due
to splinting action of limbs

Lateral Grip: Irregular parts are less felt on the side.

Pelvic grip: Small, hard and conical mass is felt. The breech is usually engaged.

FHS: Usually located at a lower level in the midline due to engagement of breech

Per vaginal Examination

Hard feel of the sacrum is felt often mistaken for the head

Palpation of ischial tuberosities, anal opening, and sacrum only

Ultrasonography

 Used to confirm the clinical diagnosis

 It can detect the congenital abnormalities of the uterus and fetus.

 It measures the bi parietal diameter, gestational age and approximate weight of the fetus.

 It also localises the placenta.

 Attitude of the head whether flexion or extension

Positions

First position - Left sacro anterior

Second Position- Right sacro anterior

Third position- Right sacro posterior

Fourth position – Left sacro posterior

Mechanism of labour
 Lie – longitudinal

Attitude – Complete flexion

Presentation- breech

Position – Left sacro anterior

Denominator- sacrum

Presenting part- anterior buttock

Engaging diameter- Bitrochantric diameter (10cm)

Sacro anterior mechanism

Buttocks:

 Engagement of Bitrochantric diameter occurs in left oblique diameter (LSA) and Right oblique diameter
(RSA). Engaging diameter is bi-trochantric with the sacrum directed towards the ilio-pubic eminence. When
the diameter passes through the pelvic brim, the breech is engaged.

 Descent takes until the anterior buttock touches the pelvic floor

 Internal rotation of the anterior buttock occurs through 1/8th of the circle placing it behind symphysis pubis

 Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under the symphysis pubis
and posterior hip sweeps the perineum

 Delivery of the trunk and the lower limbs follow

 Restitution occurs so that the buttocks may occupy original position as during engagement in oblique
diameter.

Delivery of the shoulders

 Bisacromial diameter engages in the same oblique diameter as that occupied by the buttocks at the brim soon
after the delivery of the breech

 Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the antero- posterior
diameter of the pelvic outlet. The trunk simulataneously rotates externally through 1/8 th of the circle anteriorly

 Delivery of posterior shoulder followed by anterior one is completed by anterior flexion of the delivered trunk

 Restitution and external rotation: Untwisting of the trunk occurs putting the anterior shoulder towards the right
thigh in L.S.A and left thigh in R.S.A

Delivery of head

 Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or through
the transverse diameter . The engaging diameter is suboccipito frontal (10 cm)

 Descent with increased flexion occurs

 Internal rotation of the occiput occurs anteriorly, through 1/8 th or 2/8th of the circle placing the occiput behind
the symphysis pubis.

 Further descent occurs until the sub-occiput inges under the symphysis pubis

 The head is born by flexion.

Prognosis

Maternal: Prognosis is usually good.Genital tract lacerations and haemorrhage may be caused by rapid and forceful
delivery of the baby through a pelvis that is too small.

Foetal : Causes of death or damage to the baby

1. Intracranial haemorrhage

2. Congenital malformation- congenital dislocation of Hip, Hydrocephaly, Anencephaly, and meningomylocoele

3. Asphyxia

 Prolonged compression of the umbilical cord

 Actual prolapse of the cord

 Aspiration of amniotic fluid and vaginal contents

 Prolonged and hard labour

4. Injuries: haematoma, fractures, visceral injuries, injury to nerve.

Antenatal management

 Identification of complicating factors related with breech presentation

 External cephalic version if not contraindicated

 Formulation of line of management , if the version fails or it is contraindicated.

 Identification of complicating factors: I t can be detected by clinical examination, supplemented by

sonography.

External cephalic version:

Time of version: it has been considered at 35-37 weeks but can be attempted at any time there after upto early labour.

Management of vaginal breech delivery

First stage:

The management protocol is similar to that mentioned in normal labour.

 Vaginal examination is indicated: at the onset of labour for pelvic assessment and soon after rupture of
membranes to exclude cord prolapse.

 An intravenous line is sited with Ringer’s solution , oral intake is avoided, blood is sent for group and cross
matching.

 Adequate analgesia is given, epidural is preferred.

 Fetal status and progress of labour are monitored

Second stage:

There are three methods of vaginal breech delivery:

Spontaneous: Expulsion of fetus occurs with very little assistance

Assisted breech: The delivery of the fetus is by assistance from the beginning to the end.
Breech extraction: it is rarely done these days as it produces trauma to the fetus and the mother.

Assisted breech delivery

The following are to be kept ready

1. Anaesthetist: to administer anaesthesia as and when required.

2. An assistant: to push down the fundus during contraction

3. Instruments and suture materials for episiotomy

4. A pair of obstetric forceps for the after coming head, if required

5. Appliances for revival of the baby if asphyxiated

Principles: 1). Never to rush 2) Never pull from below but push from above 3) Always keep the fetus with the back
anteriorly

Steps:

a) The patient is brought to the table when the anterior buttock and fetal anus are visible and placed in lithotomy
position

b) To avoid aortocaval compression the woman is tilted laterally using a wedge under the back.

c) Antiseptic cleaning is done, bladder is emptied with an ‘in and out’ catheter.

d) Pudendal block is done along with perineal infiltration if not epidural has been used earlier.

e) Episiotomy: It should be done in all cases of primigravidae

f) The patient is encouraged to bear down as as the expulsive forces from above ensures flexion of the fetal head
and safe descent.

g) Soon after the trunk up to the umbilicus is born the following are to be done.

 The extended legs are to be decompressed by pressure on the knees in a manner of abduction and flexion of
the thighs.

 The umbelical cord to be pulled down and to be mobilized to one side of the sacral bay to minimize
compression

 If the back remains posteriorly rotate the trunk to bring the back anteriorly

 The baby is wrapped with a sterile towel to prevent slipping when held by the hand and to facilitate
manipulation if required.

h) Delivery of the arms: The assistant is to place a hand over the fundus and steady pressure during uterine
contractions to prevent extension of arms. The arms are delivered one after the other only when one axilla is
visible.

i) Delivery of the after coming head: The following are the common methods employed.

j) Burns-Marshall method: The baby is allowed to hang by its own weight. The assistant is asked to give
suprapubic pressure with the flat of hand in a downward and backward direction; the pressure is to be exerted
more towards the sinciput. When the nape of the neck is visible under the pubic arch, the baby is grasped by
the ankles with fingers in between the two. Maintaining a steady traction and forming a wide arc of a circle,
the trunk is swung in upward and forward direction. Meanwhile, with the left hand to guard the perineum,
slipping the perineum off successively the face and brow. When the mouth is cleared off the vulva, there
 should be no hurry. Mucus of the mouth is cleared off by mucus sucker. The trunk is depressed to deliver rest
of the head.

k) Forceps delivery: Forceps can be used as a routine. The head must be in the cavity. The advantages are

 Delivery can be controlled by giving pull directly on the head and the force is not transmitted through the
neck.

 Flexion is better maintained

 Mucus can be sucked out from the mouth more effectively

The head should be brought as low down as possible by allowing the baby to hang by its own weight aided by
suprapubic pressure.

When the occiput lies against the back of the symphysis pubis, an assistant raises the legs of the child as much to
facilitate introduction of the blades from below. The head should be delivered slowly to reduce compression-
decompression forces as that may cause intracranial bleeding.

l) Malar flexion and shoulder traction (modified Mauriceau-Smellie –Veit technique): The baby is placed on the
supinated left forearm with the limbs hanging on either side. The middle and the index fingers of the left hand
are placed over the malar bones on either side. This maintains flexion of the head. The ring and little fingers
of the pronated right hand are placed on then sub-occipital region. Traction is now given downward and
backward direction till the nape of the neck is visible under the pubic arch. The assistant gives suprapubic
pressure during the period to maintain flexion. Thereafter the fetus is carried in upward and forward direction
towards the mother’s abdomen releasing the face, brow and lastly the trunk is depressed to release the occiput
and vertex.

m) Resuscitation of the baby: The baby may be asphyxiated and need to be resuscitated.

Third stage: The placenta is usually expected out soon after delivery of the head. If prophylactic ergometrine is to be
given, it should be administered intravenously with the crowning of the head.

Management of complicated breech delivery

Delay in descent of the breech

The breech may be arrested at the outlet, in the cavity or at the brim.

Arrested at the outlet: Causes are big size of the baby with extended leg, weak uterine contractions, rigid perineum
and outlet contraction

Management: place of caesarean section: If the baby is big, outlet is contracted caesarean section is done

In the absence of outlet contraction and fetopelvic disproportion: Liberal episiotomy and fundal pressure with or
without groin traction usually becomes effective. The index finger is placed in the groin fold and traction is exerted
more towards the trunk than towards the femur.

Arrest of the breech at or above the level of ischial spines: causes are contracted pelvis, weak uterine contractions
and big baby.

Management: caesarean section

Frank breech extraction (Pinard’s maneuver): Is done by intrauterine manipulation to convert a frank breech to a
footling breech. This is possible when the membranes have ruptured recently. The middle and the index fingers are
carried up to the popliteal fossa. It is then pressed and abducted so that the fetal leg is flexed. The fetal foot is then
grasped at the ankle and breech extraction is accomplished.

Extended arms:
One or both the arms may be stretched along the side of the head or lie behind the neck.

Management: The management calls for urgent delivery of the arms, first the posterior and then the anterior one.
Following methods are adopted

1. Classical: It works with the same principle as with Lovset’s maneuver. In addition it needs intrauterine
manipulation while the patient is under general anaesthetic. First the posterior arm is delivered followed by
the anterior arm. Left hand is introduced along the curve of the sacrum while the baby is pulled slightly
upwards. With firm pressure over the humerus, the posterior arm is pushed over the baby’s face. The extended
anterior arm is delivered from the anterior aspect by introducing the right hand in the same manner, while the
baby’s trunk is depressed towards the perineum.

2. Lovset’s maneuver:

Advantages:

a) Wider applicability

b) Intrauterine manipulation is nil

c) A single manipulation is effective at all types of displacement of the arms

d) General anaesthesia is usually not needed.

Principles: Because of the curved birth canal when the anterior shoulder remains above the symphysis pubis, the
posterior shoulder will be below the sacral promontory. If the fetal trunk is rotated keeping the back anterior and
maintaining a downward traction, posterior shoulder will appear below the symphysis pubis.

Procedure: The baby is grasped, using both hands by femoro-pelvic grip keeping the thumbs parallel to the vertebral
column. The manoeuvre should start only when the inferior angle of the anterior scapula is visible underneath the
pubic arch.

Step1: The baby is lifted slightly to cause lateral flexion. The trunk is rotated 180 degree keeping the back anterior and
maintaining a downward traction. This will bring the posterior arm to emerge under teh pubic arch which is then
hooked out.

Step2: The trunk is then rotated in the reverse direction keeping the back anterior to deliver the erstwhile anterior
shoulder under the symphysis pubis.

Arrest of the after-coming hand

At the brim: The causes are deflexed head, contracted pelvis and hydrocephalus.

Management: If the arrest is due to a deflexed head, the delivery is to be completed by malar flexion and shoulder
traction along with suprapubic pressure by the assistant. The head is to be negotiated through the brim in the
transverse diameter and rotated in the cavity. Forceps should not be applied in high head.

If the arrest of the head is due to contracted pelvis or hydrocephalus, perforation of head is to be done.

In the cavity: the causes are deflexed head and contracted pelvis.

Management: delivery of head by forceps

At the outlet: The causes are rigid perineum and deflexed head

Management: Episiotomy followed by forceps application or malar flexion and shoulder traction is quite effective.

Brow presentation
Brow is the rarest variety of cephalic presentation where the presenting part is brow , attitude of the head is partial
extension

Cause: same as face presentation

Diagnosis:

 delay in engagement

 Vaginal examination: Usually palpating supra orbital ridges and anterior fontanelle

 Sonography/radiography: is confirmatory and also helps in excluding bony congenital malformation of the
fetus

Mechanism of labour: no possible mechanism if baby is very small and pelvis is roomy face to pubis delivery is
possible

If the baby is small and the pelvis is roomy with good uterine contractions, delivery can occur in mento-anterior brow
position. The brow descends until it touches the pelvic floor. Internal rotation and descent occur till the root of the
nose hinges under the symphysis pubis. The brow and the vertex are delivered by flexion followed by extension to
deliver the face. There is no mechanism in posterior brow position.

Management:

During pregnancy: 1). if the presentation is diagnosed during pregnancy and there are no other contraindications for
vaginal delivery, nothing is to be done.

2). Elective caesarean section: Cases with persistent brow presentation are delivered by elective caesarean section.

During labour:

 Caesarean section is best method

 Manual correction to face with full dilatation of cervix

 Craniotomy: if the labour becomes obstructed and the baby is dead craniotomy is done.

Transverse lie

When the fetus lies with its long axis across the long axis of the uterus then the lie is transverse (shoulder
presentation)

1. Dorso posterior 2). Dorso anterior 3). Dorso-superior 4). Dorso-inferior

Incidence: 1 in 200 births, 5 times more common in multiparae than primigravidae

Causes

Maternal: a). Anterior obliquity of the uterus b). Prematurity c). Multi parity d). Poly hydramnios
e). Placenta Praevia f). Bicornuate uterus g). Contracted pelvis h). Fibroid/tumours

Fetal:

 Twins

 Macerated fetus

Diagnosis

Abdominal Examination:
 ● The abdomen is enlarged transversely, the fundal height is lower and the pelvic grip is empty

● The fetal back may be felt anteriorly(dorso anterior) or posterior with fetal limbs anteriorly on either side of
the midline

● FHS is audible below the umbilicus

Ultrasonography or radiography confirms the diagnosis

Vaginal examination:

During pregnancy: Presenting part is high

During labour: shoulders, rib cage is felt

Mechanism of labour

No mechanism in shoulder presentation. But following events may occur

1. Spontaneous Rectification or version: In 80% cases transverse lie will convert to longitudinal lie during antenatal
period.

2. Spontaneous expulsion: If fetus is small (<800gm)especially when macerated and the pelvis is large, spontaneous
expulsion is possible by a mechanism known as “ partus conduplicatio corporis” where in the fetal head and thorax,
and the body of the fetus is expelled in a horseshoe manner.

Spontaneous evolution: The arm is usually prolapsed, the head lies on one iliac fossa, trunk and the breech are forced
into the cavity, the neck is markedly elongated. Breech and the trunk are expelled first followed by delivery of the
head. This requires very strong uterine contractions.

Management

Antenatal: External cephalic version if no contraindication at 35weeks

If version fails at 37 weeks – caesarean section

Vaginal delivery may be allowed in a dead or congenitally malformed fetus by internal version and destructive
operation.

Patient seen in labour: The principles in management are:

Early labour:

● External cephalic version (provided liquor is adequate and there is no contraindication

● Caesarean section preferred method

Late Labour:

● Caesarean section if baby alive or dead.

Unstable lie

This is a condition where the presentation of the fetus is constantly changed even beyond 36 th week of pregnancy
when it should have been stabilized.
Causes:

 Grandmultipara with lack of uterine tone and pendulous abdomen

 Hydramnios

 Contracted pelvis

 Placenta praevia

 Pelvic tumour

Management

Antenatal: If there is no contraindication external version is to be done to correct the malpresentation.

Hospitalization: The patient is to be admitted at 37th week. After admission, the investigation is directed to exclude
placenta praevia, contracted pelvis or congenital malformation of the fetus with the help of sonography for
localization of the placenta.

Formulation of line of treatment

Elective caesarean section: done usually in pre-eclampsia, placenta praevia contracted pelvis.

Stabilizing induction of labour: External cephalic version is done after 37 th week. Oxytocin infusion is started to
initiate effective uterine contraction. This is followed by low rupture of the membranes. Labour is monitored for
successful vaginal delivery

To wait for spontaneous onset of labour: external cephalic version followed by ARM with or without Oxytocin.

Compound presentation

When a cephalic presentation is complicated by the presence of a hand or a foot or both alongside the head or
presence of one or both hands by the side of the breech, it is called compound presentation.

Etiology: Prematurity, contracted pelvis, pelvic tumours, multiple pregnancy, macerated fetus, high head with
premature or early rupture of the membranes and hydramnios.

Diagnosis: feeling the limb by side of the presenting part specially after the rupture of the membranes.

Management:

1. Factors to be considered are stage of labour, maturity of the fetus, singleton or twins, pelvic adequacy and
associated cord prolapse.

2. Indication of caesarean section: Mature singletone fetus associated with contracted pelvis or cord prolapse
with the fetus alive should be safely delivered by caesarean section.

3. Expectant treatment: In uncomplicated pregnancy an attitude of wait and watch policy is preferable.
Elevation of the prolapsed limb with descent of the presenting part usually takes spontaneously.

Nursing Diagnosis

1. Anxiety related to perceived or actual threats to self and fetus

2. Knowledge deficit regarding treatment needs and prognosis

3. High risk for maternal injury related to mechanical obstruction to fetal descent

4. High risk for fetal injury related to fetal malpresentation

 Conclusion

Malpresentations and mal positions are very common but careful monitoring in antenatal, intranatal and
postnatal period reduces maternal and foetal complications and mortality

Bibliography

1. Dutta DC. Text Book of Obstetrics.4th ed. Calcutta: New Central Book Agency .pg 332-341
2. Pillitteri a. Maternal and Child Health Nursing.3rd ed. Philadelphia: Lippincott publishers.1991.

3. Lowdermilk DE, Perry SE. Maternity and Women’s health care. 8th ed. Missouri Mosby; 2004.

4. Fraser DM, Cooper MA. Myles Text Book For Midwives. 14th ed. Churchill Livingstone;1991