MAL-PRESENTATIONS

Rachael Annor
Objectives
• By the end of the lesson students will be able:
• Define malpresentation
• Outline the types malpresentation
• Causes/predisposing factors of breech presentation
• Diagnosis of breech presentation
• Management of breech during labour
Introduction
• Normal presentation is defined by longitudinal lie, cephalic
presentation, and flexion of the fetal neck.
• All other presentations are malpresentations.
• E.g breech, face
• Occurring in approximately 5% of all deliveries,
• May lead to abnormalities of labor and increased risk for mother or
fetus.
Risk factors for mal-presentation 1/2
Cause unknown
• But risk factors include:
• Maternal factors include:
1. grand multiparity,
2. pelvic tumors,
3. uterine fibroids,
4. pelvic contracture,
5. uterine malformations
2/2 Fetal factors include:
• prematurity,
• multiple gestation
• polyhydramnios or oligohydramnios,
• macrosomia,
• placenta previa,
• hydrocephaly,
• trisomy
• anencephaly
BREECH PRESENTATION
• Breech presentation occurs
when the cephalic pole is in the
uterine fundus.
Types of breech presentation
1. Frank breech (48% to 73%) occurs when both hips
are flexed and both knees are extended.
2. Complete breech (5% to 12%) occurs when the fetus
is flexed at the hips and flexed at the knees.
3. Incomplete, or footling breech (12% to 38%), The
feet or knees are the lowermost presenting part:
Predisposing factors
• Prematurity
• Uterine abnormalities
• Malformation
• Fibroids
• Fetal abnormalities
• CNS Malformations
• Neck Masses
• Multiple gestations
DIAGNOSIS 1/5
• The problem can be identified during ANC and during labour
Antenatal care:
• History-
• Inspection – If the frank breech, the abdomen looks long and narrow.
In complete breech, there is no definite difference from that of a
vertex.
• Palpation - reveals palpable head in the fundus as a round hard mass;
easily balloted with one or both hands
2/5
Auscultation-The fetal heart tones are best heard
above the umbilicus when the breech has passed
through the brim.
This is because the fetal heart is further from the
buttocks than the head.
3/5
• Ultrasonic examination to confirm
• Breech presentation,
• Estimated fetal weight,
• Presenting part - footling or knee or buttocks.
• Placental site to exclude placenta praevia as cause for breech presentation.
• Exclude pelvic and uterine anomalies,
• Exclude fetal congenital anomalies such as:
• hydrocephaly.
• fetal ascites.
• spina bifida.
• renal agenesis
During Labour 4/5
• Vaginal examination
• Breech feels soft and irregular with no sutures palpable
• The sacrum may occasionally be palpated and mistaken for head
• The buttocks may be mistaken for caput succedaneum
• The external genitalia may be palpated and oedematus vulva may be
mistaken for scrutum
• There may be early rupture of membranes due to a poorly fitting
presenting part. If the breech is flexed you will feel the buttocks, the
toes or the limbs
• In breech with extended legs which is the same as frank breech, the
anal cleft and the buttocks are felt.
• In diagnosis the anus will be found to be circular and firm
• and the spinster will grip the examining fingers and when the finger is
withdrawn, meconeum may be seen on it.
5/5
•Footling presentation –
•The foot or feet may be felt.
•The midwife should confirm a footling presentation and
differentiate it from a hand by the following points.
•The toes are it from a same length
•They are shorter than the fingers
•The big toe cannot be easily moved from the other toes
MANAGEMENT OF BREECH
PRESENTATION
• Management options for singleton breech presentation
include:
• vaginal breech delivery,
• ECV with subsequent vaginal cephalic delivery if successful,
or
• elective cesarean section
Antenatal Care Management
• During pregnancy, breech presentation which persist from 32weeks
onwards should be referred to the obstrician.
• External cephalic version may be done (by those with the expertise to
do it) from 34 weeks onwards.
• At term version may be done under tocolytic cover.
• A good percentage of breech presentation turns to vertex
presentation at 40 weeks.
• Sometimes ELKIN'S MANOEUVRE is very helpful in getting the baby
turned in after the 37th week.
• The mother puts herself in the knee-chest position for minutes every 2 hours
of waking time for 5 days.
MANAGEMENT DURING LABOUR
Criteria for a planned vaginal breech birth
• Documented evidence of counselling regarding mode of birth
• Documentation of informed consent, including written consent from
the woman
• Estimated fetal weight of 2500-4000g
• Flexed fetal head
• Emergency theatre facilities available on site
• Availability of suitably skilled healthcare professional
• Frank or complete breech presentation
• No previous caesarean section.
Contraindications to vag del./ Indications
for Caesarean Section
• Cord presentation
• Fetal growth restriction or macrosomia
• Any presentation other than a frank or complete breech
• Extension of the fetal head
• Fetal anomaly incompatible with vaginal delivery
• Clinically inadequate maternal pelvis
• Previous caesarean section
• Inability of the service to provide experienced personnel.
FIRST STAGE
• The woman is reassured and her cooperation of confidence won.
• Build up her nutritional status with nourishing fluids but no solids
• Special attention to the bladder and all urine passed tested and measured
and if there is any abnormality like acetone report immediately
• Put on partograph.
• The level of descent of the presenting part (breech) is not examined in the
5th notation; the station notation is better.
• Take blood for grouping and cross matching.
• Start IV Fluids in late first stage.
• Inform Paediatric and anaesthetic teams and the Consultant
Obstetrician on duty about patient.
• Make resuscitation equipment handy.
• Continuous fetal monitoring.
• If CTG not available use fetal stethoscope but more frequently.
• Give adequate analgesia / sedation as necessary.
• Do not allow mother to push when the cervix is not fully dilated as
she may push the buttocks through undilated cervix and the after
coming head may be difficult to deliver
• Do not do ARM.
• Vaginal examination should be minimized to conserve the membranes as
long as possible and to prevent infection
• Vaginal examination is carried out as soon as the membranes rupture for
the following reasons:
• To be sure that
• the cord has not prolapsed
• To confirm the type of breech
• To identify the condition of the cervix and its dilatation
• To know the level of the breech in relation to the ischial spines
• To exclude signs of maternal and fetal distress
Management during the second stage
• BREECH: MECHANISM OF DELIVERY
• Descent of Buttock
• Flexion
• Internal Rotation of Breech
• Birth of Buttocks by Lateral Flexion
• Delivery of Legs
• Engagement of Shoulders
• Internal Rotation of Shoulders
• Birth of Shoulders by Lateral Flexion
• Descent & Engagement of Head
• Flexion
• Internal Rotation
• Birth of the Head by Flexion
Positions in Breech Presentation
Types of delivery
• Three types of vaginal breech deliveries are described, as follows:
• Spontaneous breech delivery: No traction or manipulation of the
infant is used. This occurs predominantly in very preterm, often
previable, deliveries.
• Assisted breech delivery: This is the most common type of vaginal
breech delivery. The infant is allowed to spontaneously deliver up to
the umbilicus, and then maneuvers are initiated to assist in the
delivery of the remainder of the body, arms, and head.
• Total breech extraction
Delivering the baby
• Record the fetal heart rate before the onset of 2nd stage and also after
every second contraction check the maternal pulse as well. This
should be done by a 2nd midwife.
• Do assisted breech delivery.
• Ascertain full dilatation of the cervix through vaginal examination.
• Position – Dorsal with her knees flexed and buttocks at the edges of
the bed or put her in the lithotomy position.
• Encourage her to bear down with contraction and rest in between.
• When the buttocks appear at the vulva, swab the vulva and cover the
area including the thigh with stance towel.
• In between the contractions encourage her to sip sweetening fruits
juice or glucose drinks to give energy.
• Continue to encourage her to bear down. She should be able to expel
the buttocks without help from the midwife.
• The maxim – HANDS OFF THE BREECH means that do not pull on the
breech because it will encourage premature breathing of the fetus
and also extend the head.
In a frank breech
• , the legs are extended.
• Therefore to deliver it the midwife will press on the popliteal space of the
femur that is the back of the knee of the leg which is most accessible.
• This will encourage the flexion of the knee.
• Now splint the femur and bring legs down gently.
• In a complete breech the buttocks curve upwards as the legs disengage
freely.
• After delivery of the buttocks encourage the mother to bear down with the
same contraction up to the level of the umbilicus.
• Keep the baby's back up and pull on a loop of the umbilical cord
to slacken it when the baby delivers to that level.
• Feel through gentle vaginal examination if the ELBOWS are on the chest.
Delivery of the Arms
• If Arms are felt on chest
• Allow the arms to disengage spontaneously one by one. Only assist
if necessary.
• After spontaneous delivery of the first arm, lift the buttocks
towards the mother’s abdomen to enable the second arm to
deliver spontaneously.
• If the arm does not spontaneously deliver, place one or two
fingers in the elbow and bend the arm, bringing the hand down
over the baby’s face.
• Arms are stretched above the head or folded around the neck
• Use the Lovset’s manoeuvre
• Hold the baby by the hips and turn half a circle, keeping the back
uppermost and applying downward traction at the same time, so that the
arm that was posterior becomes anterior and can be delivered under the
pubic arch.
• Assist delivery of the arm by placing one or two fingers on the upper part
of the arm.
• Draw the arm down over the chest as the elbow is flexed, with the hand
sweeping over the face.
• To deliver the second arm, turn the baby back half a circle, keeping the
back uppermost and applying downward traction, and deliver the second
arm in the same way under the pubic arch.
Delivery of the shoulders
• While the woman is pushing with the uterine contractions, grip the baby’s buttocks
with thumbs on the sacrum then the rest of the fingers round the iliac crest.
• apply downward traction to delivers the anterior shoulder from under the pubic
arch.
• delivers the posterior shoulder by lifting the buttocks slightly towards the mother’s
abdomen.
• A small stain towel may be applied around the hips to prevent the slipperiness of the
buttocks.
• It also provides warmth for the baby.
• The grasp of the baby should always be as described. It should not be on the
abdomen to prevent complications.
Deliver the After-Coming Head 1/4
• MAURICEAU - SMELIIE- VEIT technique.
• This method is also adopted if the head is extended.
• It can be identified when there is a delay in the descent or
appearance of the hair line.
• It is the midwife duty to attempt this type of delivery.
• In hospital Dr. applies the obstetric forceps whenever there is a delay
in the delivery of the head.
2/4
• The principles applied here is head flexion and shoulder traction
• Empty the bladder
• Apply moderate supra-pubic pressure to aid descent and flexion
• Place the body astride on the left arm with the palm supporting the
baby’s chest
• The middle finger of the left hand is inserted into the baby’s mouth
and the 1st and 3rd fingers on its molar bone
• The 1st and 3rd fingers of right hand are placed over the baby’s
shoulders and middle finger on the occiput
3/4
• The fingers in the mouth and that over the occiput flex the head while the
other fingers protect the jaw
• The baby straddles over the attendant's left hand.
• The fingers on the shoulders push on the head down in a downward traction.
• As the head descends traction must be applied in an outward direction until
the sub-occipital area appears.
• Then apply a traction in an upward direction to make the face visible at the
vulva
• Extract mucus from the mouth and deliver the vault of the head slowly by
movement of flexion
BURNS - MARSHALL OR LIVERPOOL
technique.
1/3
• Make sure the bladder is emptied
• Allow the baby’s delivered body to hang by its own weight for a few seconds.
• If the rotation of the head does not occur spontaneously after a few seconds
the midwife replaces her two fingers on the baby’s molar bone and gently
rotates the head.
• After rotation the sagittal suture will be in the anterior-posterior diameter of
the outlet and the fetal back will be uppermost.
• Allow the baby’s body to hang by its own weight for about 1 – 2mins.
• The neck will appear by elongating and the sub-occipital region will be felt as
the head line will appear.
2/3
• If this does not occur within 2mins assistance can gently apply supra
pubic pressure to aid descent. using the following techniques:
• When the hairline shows grasp the fetal feet
• swing the baby gently over the maternal abdomen; This
delivers the head gently. It may sometimes be necessary to
repeat the procedure several times before the head delivers.
• Clean the baby's mouth when it delivers. Vigorous traction
especially when the hairline is not showing may dislocate the
fetal neck.
MANAGEMENT OF BABY BORN
BREECH
• Baby is a tired so must be nursed as a potential cerebral baby.
• Resuscitation must be gentle.
• Injection vitamin K 0.5-1mg is given intramuscularly to stimulate the liver to
release prothrobin to arrest haemorrhage
• The baby is nursed in a quiet shaded room and is not bathed for 48hrs
• The pediatrician informed and the mother reassured.
• Observe for signs of jaundice.
• Observe for signs of tissue or nerve damage.
• Hip ultrasound scan to be performed at 6-12 weeks post birth to monitor for
developmental dysplasia of the hip (DDH).
Complications of Breech Vaginal Delivery
• Higher fetal death due to:
• Cord prolapse, prematurity, asphyxia, intracranial hemorrhage, fetal
abnormalities
• Brain damage
• Asphyxia
• Fractures