الرحمن الله الرحمن بسم الله بسمالرحيمالرحيم

MalpresentationsMalpresentations

By dr. sallama kamelBy dr. sallama kamel

Definition of malpresentationDefinition of malpresentation::

Any presentation other than vertex Any presentation other than vertex presentationpresentation..Many typesMany types::

11..Face presentationFace presentation..22..Brow presentationBrow presentation..

33..Breech presentationBreech presentation..44..ShoulderShoulder.=== .===

55..CompoundCompound .=== .===

Causes of malpresentationsCauses of malpresentations

11..PrematurityPrematurity..

22..Multiple pregnancyMultiple pregnancy..

33..Abnormal babyAbnormal baby..

44..Polyhydramnios or oligohydramniosPolyhydramnios or oligohydramnios..

55..Congenital malformation of the uterusCongenital malformation of the uterus..

66..Placenta previaPlacenta previa..

77..Contracted pelvisContracted pelvis

Face presentationFace presentationIn this condition the head is fully extended and the face In this condition the head is fully extended and the face is the presenting partis the presenting part..Incidence:Incidence: about about once in 500once in 500 labours labours..

CausesCauses::11..Abnormal baby e.g.anancephalyAbnormal baby e.g.anancephaly..

22..Congenital tumors of the neck causes extended headCongenital tumors of the neck causes extended head..33..Contracted pelvisContracted pelvis..

44..PrematurityPrematurity..55..Multiple pregnancyMultiple pregnancy..

66..Presence of several loops of cord around the neckPresence of several loops of cord around the neck..77.. Most face presentations are secondary occurs during labour as aMost face presentations are secondary occurs during labour as a

result of increased extension of the headresult of increased extension of the head..

Mechanism of labourMechanism of labour

The chin is the denominatorThe chin is the denominator..

Four positions presentFour positions present::

••Right mento-anteriorRight mento-anterior..

••Left mento-anteriorLeft mento-anterior..

••Left mento-posteriorLeft mento-posterior..

••Right mento-posteriorRight mento-posterior..

Mento-anterior positions are more common (80% Mento-anterior positions are more common (80% of cases)of cases)..

Face presentation:Face presentation: a. mento-anterior( delivery a. mento-anterior( delivery possible)possible)

b. mento-posterior (delivery impossible)b. mento-posterior (delivery impossible)..

In a mento-anterior positionIn a mento-anterior position::••The head engages and descend with increasing The head engages and descend with increasing

extensionextension..

••So the sub-mento-bregmatic diameter (9.5cm)comes So the sub-mento-bregmatic diameter (9.5cm)comes through the cervixthrough the cervix..

••When the chin reaches the pelvic floor it undergoes When the chin reaches the pelvic floor it undergoes internal rotation through one- eighth of a circleinternal rotation through one- eighth of a circle..

••So the submental region comes to lie under the So the submental region comes to lie under the subpubic archsubpubic arch..

••The head born by a movement of flexionThe head born by a movement of flexion..

••Restitution occurs and is followed by external rotation Restitution occurs and is followed by external rotation as in vertex presentationas in vertex presentation..

In mento-posterior positionIn mento-posterior position::••Similar mechanismSimilar mechanism occurs, except that the chin undergoes occurs, except that the chin undergoes

internal rotation through three-eighths of a circleinternal rotation through three-eighths of a circle..

••If the head undergoes backwards rotation there will be If the head undergoes backwards rotation there will be persistent mento-posterior positionpersistent mento-posterior position

••This position is incompatible with vaginal deliveryThis position is incompatible with vaginal delivery..

••This is because the head is already fully extended so further This is because the head is already fully extended so further extension to deliver the head is impossibleextension to deliver the head is impossible..

••This result in obstructed labour and need assisted delivery This result in obstructed labour and need assisted delivery by caesarian sectionby caesarian section..

DiagnosisDiagnosis::Abdominal examinationAbdominal examination::

••With With mento-posterior positionmento-posterior position the cephalic prominence the cephalic prominence is felt very easily to overlap the symphysis pubisis felt very easily to overlap the symphysis pubis....

••It is felt on the same side of the back and separated It is felt on the same side of the back and separated from it by deep sulcusfrom it by deep sulcus..

••It may be difficult to locate and hear the fetal heart It may be difficult to locate and hear the fetal heart soundssounds..

With mento-anterior positionWith mento-anterior position::••The cephalic prominence is difficult to feel The cephalic prominence is difficult to feel

because it lie posteriorlybecause it lie posteriorly..••The fetal heart sounds are easily heard over The fetal heart sounds are easily heard over

the chestthe chest..

Vaginal examinationVaginal examination::Early in labourEarly in labour::

••The presenting part is usually highThe presenting part is usually high..••There may be early rupture of membranesThere may be early rupture of membranes..

When labour is well established, the landmarks areWhen labour is well established, the landmarks are::••Mouth, jaws, nose, malar and orbital ridgesMouth, jaws, nose, malar and orbital ridges..

••The presence of alveolar margins distinguishes the The presence of alveolar margins distinguishes the mouth from the anus in breech presentationmouth from the anus in breech presentation..

••One should avoid damaging the eyes during vaginal One should avoid damaging the eyes during vaginal examinationexamination..

••Vaginal examination should includes a thorough search Vaginal examination should includes a thorough search for cord presentation or prolapsefor cord presentation or prolapse..

PrognosisPrognosis::

Many face presentations are delivered Many face presentations are delivered naturally without difficultynaturally without difficulty..

Face presentation is less favorable than Face presentation is less favorable than vertex because the face is a less efficient vertex because the face is a less efficient dilator of the cervixdilator of the cervix..

The diameter which emerge through the The diameter which emerge through the outlet is the sub-mento-vertical (11 cm) outlet is the sub-mento-vertical (11 cm) which is larger than the vertex presentationwhich is larger than the vertex presentation..

Management of labour and deliveryManagement of labour and delivery::

The women is kept in bed during the 1The women is kept in bed during the 1stst stage stage..

Once membranes ruptured, vaginal examination should be Once membranes ruptured, vaginal examination should be done to exclude cord prolapsedone to exclude cord prolapse..

When the cervix become fully dilated, and the head reaches When the cervix become fully dilated, and the head reaches the pelvic floor, an episiotomy should be done especially in the pelvic floor, an episiotomy should be done especially in primigravida to avoid tearing of the perineumprimigravida to avoid tearing of the perineum....

In mento-anterior positionIn mento-anterior position Spontaneous vaginal delivery is expectedSpontaneous vaginal delivery is expected..

If there is delay in the 2If there is delay in the 2ndnd stage forceps can be applied (by stage forceps can be applied (by experienced obstetrician)experienced obstetrician)

With mento-posterior positionWith mento-posterior position::

Time should be allowed for spontaneous rotation to Time should be allowed for spontaneous rotation to anterior position take place (which happened in 45-anterior position take place (which happened in 45-65% of cases)65% of cases)..

This usually happened late in the 2This usually happened late in the 2ndnd stage stage..

If spontaneous rotation does not occurIf spontaneous rotation does not occur thenthen Caesarian section done to reduce fetal and maternal Caesarian section done to reduce fetal and maternal

morbiditymorbidity..

Other indications of caesarian section areOther indications of caesarian section are::

11..Contracted pelvisContracted pelvis..

22..Big babyBig baby..

33..Cord prolapseCord prolapse..

44..Failure of descend of the presenting part in first or 2Failure of descend of the presenting part in first or 2ndnd stage of labourstage of labour..

••After delivery the face is usually swollen and After delivery the face is usually swollen and discoloreddiscolored..

••This is temporarily and complete recovery is This is temporarily and complete recovery is usual after few dayusual after few dayss..

Brow presentationBrow presentation::In brow there is partial extension of the headIn brow there is partial extension of the head..Incidence:Incidence: about about one in 1050one in 1050..Causes:Causes: The same as face presentationThe same as face presentation..

Extension of the head before labour called Extension of the head before labour called primary extensionprimary extension..Extension during labour termed Extension during labour termed secondary extensionsecondary extension..

Brow presentation is usually transientBrow presentation is usually transient..

With uterine contraction the head either undergoes more With uterine contraction the head either undergoes more flexionflexion and change to and change to vertex presentationvertex presentation..

Or further Or further extensionextension and change to and change to face presentationface presentation..Persistent brow presentation is fortunately rarePersistent brow presentation is fortunately rare..

Brow presentationBrow presentationIn brow presentation the diameter which present is the In brow presentation the diameter which present is the mento-vertical which measure 13 cmmento-vertical which measure 13 cm..

In brow presentation the diameter which In brow presentation the diameter which present is the present is the mento-vertical which measure 13 mento-vertical which measure 13 cmcm..

Such long diameter cannot engage and if Such long diameter cannot engage and if persist obstructed labour would resultpersist obstructed labour would result..

so there is no place for vaginal delivery in so there is no place for vaginal delivery in persistent brow presentationpersistent brow presentation..

only if the head is quite small in proportion to only if the head is quite small in proportion to the pelvis it may be engaged and born as browthe pelvis it may be engaged and born as brow..

DiagnosisDiagnosis::

Brow presentation can be diagnosed by ultrasound Brow presentation can be diagnosed by ultrasound antenatallyantenatally..Brow presentation should always be suspected when there Brow presentation should always be suspected when there is is non engagement of the fetal head in labour especially in non engagement of the fetal head in labour especially in woman who has had previous easy deliverieswoman who has had previous easy deliveries.. AsAs a rule there is early rupture of the membranesa rule there is early rupture of the membranes . .On vaginal examinationOn vaginal examination::

••The presenting part is usually highThe presenting part is usually high..••The landmarks felt areThe landmarks felt are::

11..The anterior fontanellsThe anterior fontanells , ,22..Frontal sutureFrontal suture..

33..ForeheadForehead . .44..The orbital RidgesThe orbital Ridges..

55..The bridge of the noseThe bridge of the nose..

ManagementManagement

When brow diagnosed ante-natally by ultrasound and When brow diagnosed ante-natally by ultrasound and

there is no evidence of disproportionthere is no evidence of disproportion oror any other any other abnormality, nothing should be done as in most cases abnormality, nothing should be done as in most cases the head will flex during labourthe head will flex during labour..

If the head is discovered to be partially extended in If the head is discovered to be partially extended in early labour and there is no evidence of disproportion early labour and there is no evidence of disproportion a short trial of labour is permitted, and this may result a short trial of labour is permitted, and this may result in further extension of the head to face presentationin further extension of the head to face presentation..

If there is persistent brow caesarian section should be If there is persistent brow caesarian section should be done as vaginal delivery is impossibledone as vaginal delivery is impossible..

Compound presentationCompound presentation::Compound presentation mean Compound presentation mean prolapse of fetal prolapse of fetal extremity alongside the presenting partextremity alongside the presenting partIt is three typesIt is three types::

11..Prolapse of the hand in cephalic presentationProlapse of the hand in cephalic presentation ) )which is the most commonwhich is the most common.(.(

22..Prolapse of upper extremity in breech Prolapse of upper extremity in breech presentationpresentation

33..Prolapse of a lower extremity in cephalic Prolapse of a lower extremity in cephalic presentation presentation (is relatively rare)(is relatively rare)..Compound presentation uncommon occur in only Compound presentation uncommon occur in only 11 in 1000 pregnanciesin 1000 pregnancies..

CausesCauses::Any factor that prevent descent of the presenting Any factor that prevent descent of the presenting part into the pelvic inlet predispose to prolapse part into the pelvic inlet predispose to prolapse of extremity alongside the presenting part e.gof extremity alongside the presenting part e.g..

11..PrematurityPrematurity..22..Cephalo-pelvic disproportionCephalo-pelvic disproportion..

33..Multiple gestationMultiple gestation..44..Grand Multiparity ( more than five deliveries )Grand Multiparity ( more than five deliveries )..

55..Hydramnios (excessive amount of amniotic fluid)Hydramnios (excessive amount of amniotic fluid)..

Cord prolapse is common occurring in about 11-20% of Cord prolapse is common occurring in about 11-20% of cases of compound presentationcases of compound presentation..

DiagnosisDiagnosis::

The diagnosis usually made during labour by The diagnosis usually made during labour by vaginal examination when the cervix dilated vaginal examination when the cervix dilated the prolapsed extremity can be felt alongside the prolapsed extremity can be felt alongside the head or breechthe head or breech..

Compound presentation should be suspected Compound presentation should be suspected when there is poor progress in labour when there is poor progress in labour especially when the fetal head fails to engage especially when the fetal head fails to engage

during the active phaseduring the active phase..

ManagementManagement::This depend onThis depend on::

11..Gestational ageGestational age..22..Type of presentationType of presentation..

in cephalic presentation with prolapsed handin cephalic presentation with prolapsed hand..Labour can be allowed and vaginal delivery anticipated as the Labour can be allowed and vaginal delivery anticipated as the hand will move upward into the lower uterine segment as the hand will move upward into the lower uterine segment as the vertex descend into the birth canalvertex descend into the birth canal..

Other compound presentation are treated by c/sOther compound presentation are treated by c/s..

There is a risk of umbilical cord prolapse and continuous fetal There is a risk of umbilical cord prolapse and continuous fetal heart monitoring should be done to detect fetal distress heart monitoring should be done to detect fetal distress

which should be treated by immediate caesarian sectionwhich should be treated by immediate caesarian section....