Malpresentation, Abnormal Position And Transverse Lie

Clinical description

Malpresentation refers to any abnormalities of the fetal presenting part, normal being cephalic presentation. Abnormal fetal position includes non-occiput anterior positioning of the fetal head during labour. With transverse lie, there is no presenting part.

Malpresentat Characteristics Diagnosis Management ion History/Exam/Investigati ons Breech • Incidence: 2-3% • Ultrasound (US) for Antenatal management of term major fetal anomalies • Perform fetal surveillance to check well being pregnancies • US for BPD, fetal • Look for possible causes of breech presentation

• Types: frank weight, placental • Caesarean delivery at 39 wks gestation for primigravida

(65%), complete location, type of • Caesarean delivery for footling breech in labour (10%), footling breech • Low threshold for Caesarean delivery (i.e. prolonged labour, (25%) complications, abnormal fetal assessment)

• Predisposing • Discuss mode of delivery with patient and offer cesarean section.

factors include: If the patient desires vaginal delivery, term pregnancy, EFW 2.5- uterine anomaly, 3.5 kg and normal pelvic dimensions abnormal o Skilled clinician at delivery amniotic fluid o Adequate analgesia volume, o No labour augmentation anencephaly, o Assist delivery of the legs, arms (Lovset manoeuvre), and hydrocephaly, head (Burn-Marshall manoeuvre, Mauriceau-Smellie-Veit reduced fetal manoeuvre or forceps) tone and multiple gestation Occiput • Membranes • Antenatal diagnosis is • Monitor progress of labour closely posterior rupture easily inaccurate; 75% of • Adequate analgesia although head is cases with occiput • IV access with NS at maintenance rate to prevent dehydration not well opposed posterior position and decrease risk of distress to cervix rotate into occiput • Fetal surveillance

• Premature anterior position

Clinical description

maternal desire • Intrapartum diagnosis Mode of delivery to push due to by VE: both • Spontaneous delivery may occur as face to pubis back pain fontanelles are • Low threshold for Caesarean delivery (i.e. relative CPD)

• Increased risk of palpable

prolonged • If moulding or caput second stage present, then feel the

• Predisposing ear to determine

factors include: position slightly smaller pelvic inlet and large fetus Occiput • Usually a • Intrapartum diagnosis • Consider oxytocin augmentation if weak contractions without transverse transitory by VE CPD (persistent) position with • Rotate head manually into occiput anterior position spontaneous • Consider outlet forceps delivery with instrumental rotation or anterior rotation vacuum assisted vaginal delivery

• Low threshold for Caesarean delivery

Brow • May be due to • Intrapartum diagnosis • May convert to vertex or face presentation in early labour with fetal neck by VE: supraorbital subsequent vaginal delivery oedema (i.e. ridges and anterior • Caesarean delivery for persistent brow presentation goiter, cystic fontanelle are hygroma) palpable Face • Suspect if • Intrapartum diagnosis • Vaginal delivery for anterior mentum prolonged first by VE: supraorbital • Caesarean delivery for posterior mentum stage of labour ridges and alveolar despite strong margins are palpable contractions and history of vaginal delivery Compound • Simultaneous • Intrapartum diagnosis • Monitor closely presentation of by VE: prolapsed • In general, leave the prolapsed extremity alone because it usually extremity next o extremity is palpable does not interfere with labour the presenting with presenting part • For prolapsed arm, monitor closely to see if arm retracts out of

Clinical description

part the way. If it does not, then gently push it upwards while pushing

• Increased risk of the head downwards by fundal pressure. If this fails, then

perinatal loss caesarean delivery.

due to preterm delivery, prolapsed cord and traumatic obstetrical procedures Transverse • Risk factors • US to confirm fetal lie • Can perform external cephalic version at 36 weeks with include: high and absence of consultant parity, preterm presenting part. • Caesarean delivery at 39 weeks gestation for persistent labour, multiple Document position of transverse lie gestation head and back. • Caesarean delivery for transverse lie in labour

• Uterine • Inspection reveals • Low vertical/classical uterine incision for transverse back

anomalies, wide abdomen with down lie placenta praevia, top of fundus only severe pelvic slightly above contracture umbilicus

• Head and buttocks are

palpable in the iliac fossae

• Intrapartum diagnosis

by VE: ribs, scapula and clavicle or should and arm are palpable