ABNORMAL

PRESENTATION
(a.k.a Malpresentation)
MOHD HAFIS ZUL ARIF BIN AWANG
MBBS 2010 – IMS – MSU
 Definition
• Presentation = fetal part in the lower part of the
uterus over the pelvic brim, that in close proximity to
the internal os of the cervix.
 e.g. Cephalic (head), Breech (buttocks) & Shoulder
• Presenting Part = the part of the presentation which
lies immediately inside the internal os.
 Determined by vaginal examination in labour
 Vertex, Brow or Face
• Malpresentation = any presentation other than a
vertex lying in close proximity to the internal os of
the cervix.
• Vertex = the area of fetal skull bounded by the two
parietal eminence and the anterior and posterior
fontanelles.
 This is the presenting part of 95% normal term
labour.
 Overview
• Normal Presentation is CEPHALIC and WELL-
FLEXED VERTEX
 Causes
a) Idiopathic (most common) • Multiple preganancy
b) Maternal • Intrauterine death
• Multiparity Macrosomia
• Pelvic tumors • Fetal abnormality (eg:
hydrocephalus,
• Congenital uterine
anencephaly, cystic
anomalies
hygroma)
• Contracted pelvis
d) Placental
c) Fetal
• Placenta praevia
• Prematurity
• Polyhydromnios
• Amniotic bands
 Types
A. Cephalic: Face & Brow
B. Breech (3-4%): Extended, Flexed & Footling
C. Transverse
D. Compound
E. Shoulder
A) Cephalic
1. Normal Presentation: Vertex
• Normal Attitude: Fetus is in full flexion
• Every fetal joint is flexed
• Smallest fetal head diameter:
Suboccipitobregmatic (9.5cm)
2) Abnormal Presentations: Extended Attitude
a) General
– Abnormal Attitude: Fetal head is extended
– Results in largest head diameter: Occipitomental
(11.5 cm)
– Increases diameter 3 cm (24%) over flexed head
– May results in Failure to Progress
b) Face Presentation
c) Brow Presentation
d) Shoulder Presentation
3. Abnormal Presentation: Asynclitism
• Definition
– Lateral flexion of head
– Sagittal Suture not in midline of vaginal canal
• Interpretation
– Mild asynclitism is normal
– Extreme asynclitism interferes with delivery
» May result in failure to progress
» Interferes with forceps application
B) Breech
• Definition = baby’s buttocks lie over maternal pelvis.
 Lie is longitudinal
 Head is found in the fundus
• Breech delivery is the single most common abnormal
presentation.
• The incidence is highly dependent on the gestational age.
More common in preterm.
• Not important before 34-36 unless woman in labour.
• At 20 weeks, about one in four pregnancies are breech
presentation. By full term, the incidence is about 4%.
• Types of Breech
 Flexed / Complete / Full breeches (15%): legs
flexed at the knees so that both buttocks and feet
are presenting.
 Extended / Frank breeches (70%): both legs
extended with feet by head; presenting part is the
buttocks.
 Footling / Incomplete breeches (15%): one leg
flexed and one extended. Can be ‘single’ or ‘double’
footling
• Consequences
 Fetal: increased risk of hypoxia, trauma in labor.
 Maternal: delivered by CS
• Diagnosis
 History: breech in early pregnancy and previous
delivery, uterine fibroids and malformation
 Examination: longitudinal lie, head palpated at fundus,
presenting part not hard, fetal heart best heard high up
on uterus.
 Investigation: Confirmed with USG; should asses
growth anomaly, neck hyperextension, liquor, EFW,
placental site
• Management of Breech
a) External Cephalic Version (ECV)
 May be undertaken from 34th week gestation
 Containdication:
i. Absolute – multiple pregnancy, APH, placenta
previa, ROM, fetal abnormality.
ii. Relative – previous CS, IUGR, Rh-isoimmunization
b) Vaginal Breech Delivery
• Favorable vs. Unfavorable for Vagina Delivery
 Previous delivery of normal-sized infant / Nulliparity,
other indication for CS
 EFW: 2-3.8kg / EFW >3.8kg
 Extended breech / Footling breech, hyperextended
neck
 Normal liquor / oligo- or polyhydromnios
 Maternal desire for vaginal delivery / CS
 Gestation > 33 weeks / Previous CS
 Grossly contracted pelvis
OR
1. Lateral flexion of trunk required to allow progress
2. Deliver one leg at a time
3. Deliver anterior shoulder blade and arm
4. Grasped ankles and swung upwards  permits
posterior arm freed.
5. Body allowed to hang till head descends into
pelvis and hair line shows.
6. Head my be delivered using forceps OR
7. The Mauriceau-Smellie-Viet manoeuvre: Traction
by index, middle and ring finger to promote head
flexion. Other hand support fetal back OR
8. The Burns-Marshall method: feet are grasped with
gentle traction arc over maternal abdomen 
mouth freed  delivery completed by further
swinging over maternal abdomen.
N.B:
 Delivery of head as slow as possible to decrease damage to
skull membrane by sudden compression and release
 Air passage should be cleared as quickly as possible by
aspirating nose and mouth
c) Breech Extraction
• Obstetrician places hand inside the uterus and
grasps the foot.
• Baby delivered by traction of the foot
• Procedure now restricted to delivery of second
twin (lying transverse and membrane ruptured)
• If membrane intact, ECV possible.
d) Caesarean Section
C) Transverse
• Transverse lie occurs frequently in early pregnancy, when it is
of no consequence. At 16 weeks gestation, about half of all
pregnancies will be transverse lie. This number steadily falls
as pregnancy advances and the incidence of transverse lie by
the 28th week is well below 10%. It falls steadily thereafter.
• If the fetus remains in a transverse lie, it cannot be delivered
vaginally as the diameter of the fetal presenting part (the
whole body, in this case) cannot descend through the birth
canal.
• Complication: ruptured uterus, prolapse umbilical cord.
 For these reasons, women found to have a transverse lie in
labor will usually have a CESAREAN SECTION.
• Exceptions to this indication for cesarean section:
 If labor is occurring during the middle trimester and fetus is
not considered viable, it may be possible for this very small
and fragile fetus to compress enough to squeeze through the
pelvis. In this case, fetal survival would not be an issue.
 It may be possible to perform an external version,
 In the case of twins, it would be acceptable to allow labor,
even though the second twin is in transverse lie, anticipating
that after delivery of the first twin, you would reach in and
perform an internal version, converting the transverse lie to
cephalic or breech presentation prior to delivery.
• Management:
 Evaluate the patient carefully with ultrasound to

determine if there are any predisposing factors,

such as a placenta previa or pelvic kidney that
could modify your management of the patient.
 So long as a placenta previa is not present, many

obstetricians will check the patient's cervix at

frequent intervals to detect early cervical dilatation
and the consequential increased risk of cord
prolapse.
 Sometimes, these patients are delivered early by

scheduled cesarean section to avoid that risk.

D) Compound
• Compound presentation means that a fetal hand is
coming out with the fetal head. This is a problem
because:
 The amount of baby that must come through the
birth canal at one time is increased.
 There is increased risk of mechanical injury to the
arm and shoulder, including fractures, nerve injuries
and soft tissue injury.
• A compound presentation may be resolvable if the
fetus can be encouraged to withdraw the hand, for
example.
• If the fetus and arm are relatively small in
comparison to the maternal pelvis, vaginal delivery
may still be possible, but with some risk of injury to
the arm.
• If the fetus and arm are relatively large in
comparison to the maternal pelvis, obstructed labor
will occur and a cesarean will be needed.
E) Shoulder
• Shoulder presentation means that the fetal shoulder
is trying to come out first. This is a more advanced
form of transverse lie and is undeliverable vaginally.
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