Obstetric Complications

MALPOSITIONS AND MALPRESENTATIONS

 MALPOSITIONS AND
MALPRESENTATIONS
 Malpositions are abnormal positions of the
vertex of the fetal head (with the occiput as the
reference point) relative to the maternal pelvis.
 Malpresentations are all presentations of the
fetus other than vertex.
 The fetus is in an abnormal position or
presentation that may result in prolonged or
obstructed labour.
 GENERAL MANAGEMENT
• Perform a rapid evaluation of the general condition of the
woman, fetal heart rate
• If the membranes have ruptured, note the colour of the
draining amniotic fluid:
• The presence of thick meconium indicates the need for
close monitoring
• The absence of fluid draining after rupture of the
membranes is an indication of reduced volume of
amniotic fluid, which may be associated with fetal
distress
• Provide encouragement and supportive care.
• Review progress of labour using a partograph.
 DIAGNOSIS
• The most common presentation is the vertex of
the fetal head. If the vertex is not the presenting
part is called malpresentation.
• If the vertex is the presenting part, use
landmarks of the fetal skull to determine the
position of the fetal head.
DIAGNOSIS
 DETERMINE THE POSITION OF THE
FETAL HEAD
• The fetal head normally engages in the maternal
pelvis in an occiput transverse position, with the
fetal occiput transverse in the maternal pelvis.
 DETERMINE THE POSITION OF THE
FETAL HEAD
• With descent, the fetal
head rotates so that the
fetal occiput is
anterior in the
maternal pelvis. Failure
of an occiput
transverse position to
rotate to an occiput
anterior position should
be managed as an
occiput posterior
position.
 ETERMINE THE POSITION OF THE
FETAL HEAD
• If the fetal head is well-flexed with
occiput anterior or occiput
transverse (in early labour), proceed
with birth of the baby.
• If the fetal head is not occiput
anterior, identify and manage the
malposition.
• If the fetal head is not the
presenting part or the fetal head is
not well-flexed, identify and
manage the malpresentation.
 Diagnosis of malpositions
• Occiput posterior position occurs
when the fetal occiput is posterior in
relation to the maternal pelvis.
• On abdominal examination, the
lower part of the abdomen is
flattened, fetal limbs are palpable
anteriorly and the fetal heart may be
heard in the flank.
• On vaginal examination, the
posterior fontanelle is towards the
sacrum and the anterior fontanelle
may be easily felt if the head is
deflexed.
• Occiput transverse position occurs when the fetal
occiput is transverse to the maternal pelvis.
• If an occiput transverse position persists into the later
part of the first stage of labour, it should be managed as
an occiput posterior position.
 SPECIFIC MANAGEMENT
OCCIPUT POSTERIOR POSITIONS
• Spontaneous rotation to the anterior position occurs in
90% of cases.
• Arrested labour may occur when the head does not
rotate and/or descend.
• Birth of the baby may be complicated by perineal tears
or extension of an episiotomy.
• If there are signs of obstruction but the fetal heart rate
is normal, allow the woman to walk around or change
position to encourage spontaneous rotation.
• If there are signs of obstruction and the fetal heart
rate is abnormal at any stage, perform a caesarean.
 SPECIFIC MANAGEMENT
OCCIPUT POSTERIOR POSITIONS
• If the cervix is not fully dilated and there are no signs
of obstruction, augment labour with oxytocin.
• If the cervix is fully dilated but there is no descent in
the expulsive of the second stage of labour, assess for
signs of obstruction. If there are no signs of
obstruction, augment labour with oxytocin
• If the cervix is fully dilated:
• - If the fetal head is no more than 2/5 above the
symphysis pubis, or the leading bony edge of the fetal
head is at 0 station, assist birth of the baby using an
obstetric vacuum or forcep. - Otherwise, perform a
caesarean.
• In brow presentation, engagement is usually
impossible and arrested labour is common.
Spontaneous conversion to either vertex
presentation or face presentation can rarely
occur, particularly when the fetus is small or
when
• there is fetal death with maceration. It is unusual
for spontaneous conversion to occur with an
average-sized live fetus once the membranes
have ruptured.
 Brow presentation
• Brow presentation is caused
by partial extension of the
fetal head so that the occiput
is higher than the sinciput.
• On abdominal examination,
more than half the fetal head
is above the symphysis
pubis and the occiput is
palpable at a higher level than
the sinciput.
• On vaginal examination, the
anterior fontanelle and the
orbits are felt.
 SPECIFIC MANAGEMENT
brow presentation
• If the fetus is alive, perform a caesarean.
• If the fetus is dead:
- If the cervix is not fully dilated, perform a
caesarean.
• - If the cervix is fully dilated:
• – Perform a craniotomy.
• – If the operator is not proficient in craniotomy,
perform a caesarean.
 Face presentation
• Face presentation is caused by
hyperextension of the fetal head
so that neither the occiput nor the
sinciput is palpable on vaginal
examination
• On abdominal examination, a
groove may be felt between the
occiput and the back.
• On vaginal examination, the face
is palpated, the examiner’s finger
enters the mouth easily and the
bony jaws are felt.
 Specific Management
Face presentation
• CHIN-ANTERIOR POSITION:
• If the cervix is fully dilated:
• - Allow normal childbirth to proceed.
• - If there is slow progress and no sign of obstruction,
augment labour with oxytocin.
• - If descent is unsatisfactory, assist the birth of the baby
using forceps.
• If the cervix is not fully dilated and there are no signs
of obstruction, augment labour using oxytocin, Review
progress as with vertex presentation.
 Specific Management
Face presentation
• CHIN-POSTERIOR POSITION:
• • If the cervix is fully dilated or not fully dilated perform a
caesarean.
• • If the fetus is dead:
• - Perform a craniotomy
• - If the operator is not proficient in craniotomy, perform a
caesarean.
 Compound presentation
• Compound presentation occurs
when an arm prolapses
alongside the presenting part.
• Both the prolapsed arm and
the fetal head present in the
pelvis simultaneously.
 Specific Managemant
Compound presentation
• Spontaneous vaginal birth can occur only when the fetus
is very small or dead and macerated.
• Arrested labour occurs in the expulsive phase of the
second stage of labour.
• Replacement of the prolapsed arm is sometimes
possible:
• - Assist the woman in assuming the knee-chest
position.
• - Push the arm above the pelvic brim and hold it there
until a contraction pushes the head into the pelvis.
• - Proceed with management for normal childbirth
 Specific Managemant
Compound presentation
 Breech presentation
•
Breech presentation occurs when the buttocks and/or
the feet are the presenting parts.
• On abdominal examination, the head is felt in the
upper abdomen and the breech in the pelvic brim.
• Auscultation locates the fetal heart higher than
expected with a vertex presentation.
• On vaginal examination during labour, the buttocks
and/or feet are felt; thick, dark meconium is normal.
 Types of Breech
 Complete (flexed) breech
presentation occurs when both legs
are flexed at the hips and knees.

 Frank (extended) breech

presentation occurs when both legs
are flexed at the hips and extended at
the knees.

 Footling breech presentation occurs

when a leg is extended at the hip and
the knee.
 Specific Management
Breech Presentation
• EARLY LABOUR:
• Attempt external cephalic version
• vaginal birth is possible;
• there are no complications (e.g. fetal growth restriction,
uterine bleeding, previous caesarean birth, fetal
abnormalities, twin pregnancy, hypertension, fetal death).
• If external version is successful, proceed with normal
childbirth.
• • If external version fails, proceed with vaginal breech
birth (below) or caesarean.
 Specific Management
Breech Presentation
• VAGINAL BREECH BIRTH:
• A vaginal breech birth by a skilled health care provider is
safe and feasible under the following conditions:
 - complete or frank breech
 - adequate clinical pelvimetry;
 - fetus is not too large;
 - no previous caesarean for cephalopelvic disproportion;

 - fetal head is flexed.

 Specific Management
Breech Presentation
• Examine the woman regularly and record progress on a
partograph
• • If the membranes rupture, examine the woman
immediately to exclude cord prolapse.
• • Note: Do not rupture the membranes.
• • If the cord prolapses and birth is not imminent, perform
a caesarean
• • If there are fetal heart rate abnormalities ) or prolonged
labour, perform a caesarean
• Note: Meconium is common with breech labour and is
not a sign of fetal distress if the fetal heart rate is normal.
 COMPLICATIONS
Fetal complications of breech presentation include:
 • cord prolapse;
 • birth trauma as a result of extended arm or
head, incomplete dilatation of the cervix, or
cephalopelvic disproportion;
 • asphyxia from cord prolapse, cord
compression, placental detachment or
entrapped head;
 • damage to abdominal organs; and
 • broken neck.
 Specific Management
Breech Presentation
• CAESAREAN BIRTH FOR BREECH PRESENTATION
• • A caesarean birth is safer than vaginal breech birth and
recommended in cases of:
 - double footling breech;
 - a small or malformed pelvis;
 - a very large fetus;
 - a previous caesarean for cephalopelvic disproportion
 - a hyperextended or deflexed head.
• Note: Elective caesarean does not improve the outcome
in preterm breech birth.
 Transverse presentation
• Transverse lie and shoulder
presentation occur when the long axis
of the fetus is transverse. shoulder is
typically the presenting part.
• On abdominal examination, neither
the head nor the buttocks can be felt at
the symphysis pubis and the head is
usually felt in the flank.
• On vaginal examination, a shoulder
may be felt, but not always. An arm
may prolapse, and the elbow, arm or
hand may be felt in the vagina.
 Specific Management
Transverse Presentation
• If a woman is in early labour and the membranes are
intact, attempt external version
• In modern practice, persistent transverse lie in labour is
managed by performing a caesarean whether the fetus
is alive or dead.