MALPRESENTATIONS

Liji Raichel Kurian

Dept of OBG
Fetal Malpresentation
Presentation
It refers to the part of the fetus which lies in
the pelvic brim or lower pole of uterus.
Malpresentation
Malpresentations are all presentations of the
fetus other than vertex.
It may be identified late in pregnancy or may
not be discovered until the initial assessment
during labor.
 Related Factors

 The woman has had more than

one pregnancy
 There is more than one fetus in
the uterus
 The uterus has too much or too
little amniotic fluid
 The uterus is not normal in
shape or has abnormal growths,
such as fibroids
 placenta previa
 The baby is preterm
 Types of Malpresentation
BREECH
Complete (Flexed) Breech Presentation
Footling Breech Presentation
Frank (Extended legs) Breech Presentation
Kneeling Breech Presentation

VERTEX
Brow Presentation
Face Presentation
Shoulder Presentation
Unstable lie
Compound presentation
The diagnosis of abnormal fetal presentations is commonly made with a
combination of Leopold’s Maneuver,Vaginal examination, and Ultrasound
INTRODUCTION
 A breech birth is the birth of a baby
from a breech presentation, in which
the baby exits the pelvis with the
buttocks or feet first as opposed to the
normal head-first presentation. In
breech presentation, fetal heart
sounds are heard just above the
umbilicus. In a breech presentation,
the lie is longitudinal and the podalic
pole presents at the pelvic brim. It is
the commonest malpresentation.
DEFINITION
 It
is a longitudinal lie in which
the buttocks is the presenting
part with or without the lower
limbs.
According to Nima Bhaskar
INCIDENCE
 3-4% of fetus present by breech at term
 5% at 34 weeks
 20% at 28 weeks
 20% diagnosed initially in labour
 3.5% term singleton deliveries and about 25% of
cases before 30 weeks of gestation undergo
spontaneous cephalic version up to term.
TYPES

Complete Breech Incomplete

(Flexed Breech) Breech(30-35%)
1. Complete Breech (Flexed Breech)

The thighs are flexed at

The normal attitude of full
the hips and the legs at
flexion is maintained.
knees.

The presenting part

consists of two buttocks, It is commonly present in
external genitalia and two multiparae.
feet.
 INCOMPLETE BREECH
Frank Breech
• It is breech with extended legs where the knees are
extended while the hips are flexed.
• More common in primigravida.

Footling Presentation
• The hip and knee joints are extended on one or both sides.
• More common in preterm singleton breeches.

Knee Presentation
• The hip is partially extended and the knee is flexed on one
or both sides
BREECH PRESENTATION
 CLINICAL VARIETIES

Uncomplicated Complicated
When the
It is defined as one
presentation is
where there is no
associated with
other associated
conditions which
obstetric
adversely influence
complications apart
the prognosis such as
from the breech,
prematurity, twins,
prematurity being
contracted pelvis,
excluded.
placenta praevia etc.
POSITIONS

Left Sacroanterior Left Sacroposterior Left Sacrolateral

(LSA) (LSP) (LSL)

Right Sacroanterior Right Right Sacrolateral

(RSA) Sacroposterior (RSL)
(RSP)
Etiology Of Breech Presentation

Prematurity

Factors preventing
spontaneous version

Favorable adaptation

Undue mobility of the fetus

Fetal abnormality
 DIAGNOSIS

CLINICAL
SONOGRAPHY
RADIOLOGY
CLINICAL
Complete Breech Frank Breech

Per Abdomen

Fundal Grip  Head- suggested by hard and  Head

globular mass  Irregular small parts
 Head is ballottable of the feet may be
felt by the side of the
head.
 Head is non-
ballottable due to
splinting action of
the legs on the
trunk.
Lateral Grip  Fetal back is to one side and  Irregular parts are
the irregular limbs to the less felt on the side
other
CLINICAL
Complete Breech Frank Breech

Pelvic Grip  Breech- suggested by soft, broad and  Small, hard and a conical
irregular mass. mass is felt
 Breech is usually not engaged  The breech is usually
during pregnancy engaged

F.H.S.  Usually located at a higher level • Located at a lower level in

round about the umbilicus the midline due to early
engagement of the breech

Per Vaginum
During Pregnancy  Soft and irregular parts are felt  Hard feel of the sacrum is
through the fornix felt, often mistaken for the
head
During labour  Palpation of ischial tuberosities,
sacrum and the feet by the sides of • Palpation of ischial
the buttocks tuberosities, anal opening
 The foot felt is identified by the and sacrum only
prominence of the heel and lesser
mobility of the great toe.
Ultrasonography
1. It confirms the clinical diagnosis- specially in
primigravidae.
2. It can detect fetal congenital abnormality and also
congenital anomalies of the uterus.
3. Type of breech (complete or incomplete).
4. It measures biparietal diameter, gestational age and
approximate weight of the fetus.
5. It also localizes the placenta.
6. Assessment of liquor volume (important for ECV).
7. Attitude of the head- flexion or hyperextension
(Important for decision making at the time of delivery).
8. CT and MRI can be used to assess the pelvic capacity in
addition to all the above mentioned information.
Mechanism of LSA
 Lie – longitudinal
 Attitude- complete flexion
 Presentation- breech
 Position- LSA
 Denominator- sacrum
 Presenting part- anterior (left) buttocks
 Bitrochantric diameter 10cm enters the
pelvis in left oblique diameter
 Sacrum points the left ileopubic eminence.
MECHANISM OF LABOUR

Delivery of the
buttocks

Shoulders

Head
 MECHANISM OF LABOUR
 Compaction
 Internal rotation of the buttocks
 Lateral flexion of the body
 Restitution of the buttocks
 Internal rotation of the shoulders
 Internal rotation of the head
 External rotation of the body
 Birth of the head
Delivery of Buttocks
• The engagement diameter is the bitrochantric diameter 10 cm which enters the pelvis
in one of the oblique diameters.

• Descent of the buttocks occurs until the anterior buttock touches the pelvic floor.

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

• Further descent with lateral flexion of the trunk occurs until the anterior hip hinges
under the symphysis pubis which is released first followed by the posterior hip.

• Delivery of the trunk and the lower limbs follow.

• Restitution occurs so that the buttocks occupy the original position as during
engagement in oblique diameter.
Delivery of Shoulders
• Bisacromial diameter (12 cm or 4 ¾”) engages in the same oblique
diameter as that occupied by the buttocks at the brim soon after the
delivery of 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 simultaneously rotates externally through 1/8th of a circle.

• Delivery of the posterior shoulder followed by the anterior one is

completed by anterior flexion of the delivered trunk.

• Restitution and external rotation :

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 of the head is
suboccipito-frontal (10 cm).

• Descent with increasing flexion occurs.

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

• Further descent occurs until the sub-occiput hinges under the symphysis pubis.

• The head is born by flexion- The chain, mouth, nose, forehead, vertex and occiput
appearing successively.The expulsion of the head from the pelvic cavity depends
entirely upon the bearing efforts and not at all on uterine contractions.

• Sacro-posterior position: The mechanism is not substantially modified. The head

has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.
PROGNOSIS

MATERNAL

FETAL
The Fetal Dangers
• Intracranial Haemorrhage
• Asphyxia
• Injuries
Prevention of the Fetal Hazards
• The incidence of breech can be minimized by external cephalic
version where possible.
• If the version fails or is contraindicated, delivery is done by
elective caesarean section.
• A skilled obstetrician along with an organized team consisting of
a skilled anesthetist and an assistant should conduct vaginal
breech delivery.
• Vaginal manipulative delivery should be done by a skilled person
with utmost gentleness, specially during delivery of the head.
 Identification of
the complicating
factors

ANTENATAL
MANAGEMEN
T

Formulation External
of the line of cephalic
management version
 External Cephalic Version

Indications:

Procedure

Preliminaries

Benefits of External Cephalic Version

Causes of failure of version

Dangers of Version

Management, if version fails or is contraindicated

ELECTIVE CAESARIAN SECTION

Indications for
During First Stage
caesarian

Big Baby (estimated fetal weight>3.5 Cases seen first time in labour with
kg) presence of complications

Hyperextension of the head Arrest in the progress of labour

Footling presentation (risk of cord

Non-reassuring FHR pattern
prolapse)

Suspected pelvic contraction Cord presentation or prolapse

Any obstetrical or medical

complications
VAGINAL BREECH DELIVERY

Indications for vaginal breech Management of Vaginal

delivery Breech Delivery

Adequate pelvis First Stage

Average fetal weight (1.5-3.5 kg) Second Stage

Flexed head and without any other

complications
ASSISTED BREECH DELIVERY

Preliminaries for conduction

Principles in conduction
of normal labour

Anaesthetist to administer Never to rush

anaesthesia as and when required
An assistant to push down the fundus
Never pull from below but push from above
during contractions.

Instruments and suture materials for Always keep the fetus with the back
episiotomy anteriorly.

A pair of obstetric forceps for the after

coming head, if required.

Appliances for revival of the baby, if

asphyxiated
ASSISTED BREECH DELIVERY

Delivery of the after coming

Steps Third Stage
head

Patient is to be placed in lithotomy

position when the posterior buttock Burn-Marshall method
distends the perineum.

To avoid aortocaval compression Forceps delivery

Malar Flexion and Shoulder
Antiseptic cleaning
traction (modified
Mauriceau-Smellie- Veit
technique)
Pudendal block Resuscitation of the baby

Episiotomy

Patient is encouraged to bear down

Soon after the trunk upto the umbilicus

is born

Delivery of the arms

 Delayed in
Descent of the
Breech

MANAGEMENT OF
COMPLICATED
BREECH DELIVERY

Arrest of the
After-coming Extended Arms
Head
Delayed in Descent of the Breech

Arrested at the Outlet

In the absence of outlet contraction

and feto-pelvic disproportion

Arrest of the breech at or above the

level of ischial spines

Frank Breech Extraction (Pinard’s

Maneuver)
Extended Arms
Extended arms is due to faulty technique in delivery using unnecessary
traction, forgetting the principle of ‘never pull but push from above’

Diagnosis is made by noting the winging of the scapula and absence

of the flexed limbs in front of the chest.

Management :

The management calls for the urgent delivery of the arms, first the
posterior and then the anterior one.

The delivery of the arm may be accomplished by adopting any one of

the following methods:

Classical

Lovset
 Arrest of After Coming Head

At the Brim

In the Cavity

At the Outlet

Delivery of the head through an incompletely dilated cervix

Occipito- posterior position of the head through an incompletely

dilated cervix
CONCLUSION:
The incidence of Breech presentation
expected to be low in hospitals where high parity
births are minimal and routine external cephalic
version done in antenatal period. Breech presentation
can be managed by early diagnosis and effective
management strategies. By using different maneuvers
and skillful observation of the obstetrician.