MALPRESENTATION AND MALPOSITIONINTRODUCTION Near term and during labour, the foetus normally assumes a longitudinal lie and presents with the cephalic pole to the maternal pelvis with the neck flexed and the vertex in the lowermost part of the uterus. In approximately 5% of labours, the lie is not longitudinal. This is usually associated with dangers to both mother and fetus and demands intervention. malposition A fetal malpositions refers to when the fetal vertex presents to the maternal pelvis in a position other than an occipitoanterior position. malpresentation A condition in which a baby is not in the usual head-first position for childbirth. Malpresentation includes breech presentation (the baby’s bottom appears first), face presentation, and shoulder presentation (in which the baby is lying across the uterus). Breech presentations are the most common. classification Thus the various presentations are: cephalic presentation (head first): vertex (crown) sinciput (forehead) brow (eyebrows) Face chin . breech presentation (buttocks or feet first): complete breech footling breech frank breech Arm Shoulder trunk shoulder presentation: . Attitude Definition: Relationship of fetal head to spine: flexed. extended . (this is the normal situation) neutral (“military”). LOA . Cephalic presentation a.LOP .ROA .position Definition: Relationship of presenting part to maternal pelvis: and based on presentation: 1. Vertex with longitudinal lie .ROP . LSA .RSP . Face presentation 2.OP . Breach presentaion .RSA ..OA b.LSP . SA .SP 3. Shoulder presentation with transverse lie Left scapula-anterior (LSA) Right scapula-anterior (RSA) Left scapula-posterior (LSP) Right scapula-posterior (RSP) .. . (unstable. will eventually become either transverse or longitudinal) transverse (resulting in shoulder presentation).Lie Definition: Relationship between the longitudinal axis of fetus and maternal pelvis longitudinal. (resulting in either cephalic or breech presentation) oblique. OCCIPITO POSTERIOR POSITION . INTRODUCTION Occipito posterior positions are the most common type of the occiput and occur in approximately 10% of labours. All the three position( LOP. ROP. . This occurs in 5% of deliveries. A persistent occipito posterior position results from a failure of internal rotation prior to delivery. OP) may be primary or secondary. DEFINITION In a vertex presentation where the occiput is placed posteriorly over the sacroiliac joint or directly over the sacrum. . it is called an occipito posterior position. more than 50% is associated with either anthropoid or android pelvis .causes Shape of the pelvic inlet . Abruptio placenta Brachycephaly (flat head syndrome) Uterine factors .Abnormal uterine contraction .Fetal factors .Marked deflexion of the fetal head. DIAGNOSIS . ANTENATAL ABDOMINAL EXAMINATION ON INSPECTION there is a saucer shaped depression at or just below the umbilicus. ON PALPATION While the breech is easily palpated over the fundus the back is difficult to palpate Limbs can be felt on both sides of the midline. Non engagement of the head . Women may have strong desire to push In-coordinated contraction . Diagnosis during labor Women complain of continuous and severe back pain Slow decent of head. However the heart may be heard more easily at the flank on the same side as the back.On auscultation the fetal back is not well flexed so the chest is thrust forward. therefore the fetal heart can be heard in the midline. The anterior fontanelle is felt more easily because of deflexion of the head In late labour Diagnosis is difficult because of caput formation. . Posterior fontanalle is felt near the sacroiliac joint.Vaginal examination The findings in early labour are Elongated bag of membranes The sagittal suture occupies the any of the oblique diameter of the pelvis. USG It is rarely done. It is helpful to know the descent. . attitude for the head and its relation to the pelvic walls (position). The engaging transverse diameter is biparietal (9.MECHANISM OF THE OCCIPITO POSTERIOR POSITION In the occiput posterior position.5cm).5cm) and the anteroposterior diameter is either suboccipitofrontal (10cm) or occipitofrontal (11. the head engages in the right oblique diameter for the ROP and in the left oblique diameter for the LOP. . .POSSIBLE COURSES OF LABOUR LONG INTERNAL ROTATION: This is the commonest outcome with increasing flexion the occiput reaches the pelvic floor and rotates 3/8th of a circle forward to an occiput anterior position. In about 90% delivery occurs in thin manner. Mechanisms will then continue as in an anterior position (LOA or ROA). SHORT INTERNAL ROTATION Chance for two possible outcomes Face to pubis delivery Persistent occipito posterior position The term persistent occipito posterior position indicates that the occiput fails to rotate forwards. The baby is born facing the pubic bone (face to pubis). The occiput goes into the hollow of the sacrum. . Instead the sinciput reaches the pelvic floor first and rotates forwards. Arrest may be due to weak contractions.Deep transverse arrest The head descends with some increase in flexion. flexion is not maintained and the occipitofrontal diameter becomes caught at the narrow bispinous diameter of the outlet. The occiput reaches the pelvic floor and begins to rotate forwards. a straight sacrum or a narrowed outlet . MECHANISAM OF ROP Lie .Longitudinal Attitude – deflexed Presentation – Vertex Position – ROP Denominator – occiput Presenting part – middle or anterior area of the left parietal bone . Flexion Internal rotation of the head Crowning Extension Restitution Internal rotation of the shoulder External rotation of the head Lateral flexion . complication Obstructed labour Maternal trauma Neonatal trauma Cord prolapsed Cerebral haemorrhage . Management Principles: Early diagnosis. if necessary. Strict vigilance with watchful expectancy hoping for descent and anterior rotation of the occiput. . Judicious and timely interference. . Pelvic inadequacy or its unfavourable configuration. big baby usually need caesarean section. post caesarean pregnancy.Early CS occipito posterior per se is not an indication of caesarean section. preeclampsia. along with obstetric complications such as. Progress of labour is judged by Progressive descent of the head Rotation of the back and the anterior shoulder towards the midline. Increasing flexion of the head Position of the sagittal suture on vaginal examination Cervical dilatation.First stage: Can do normally. Anticipating prolonged labor. . intravenous infusion line is sited and ringer’s solution drip is started. The following are the instructions need to follow. Indication of caesarean section: arrest of labour. In such a situation.Weak pain. incordinate uterine action. oxytocin infusion is started for augmentation of labour. persistence of deflexion and nonrotation of the occiput are the triad too often coexistent. . fetal distress. In such cases. proper conduction of delivery and liberal episiotomy should be done to prevent complete perineal tear.In occipito-sacral position. spontaneous delivery as face to pubis may occur. In minority (unrotated and malrotated): . .Second stage In majority anterior rotation of the occiput is complicated and the delivery is either spontaneous or can be accomplished by low forceps or ventouse.watchful expectancy for the anterior rotation of the occiput and descent of the head . .25mg with the delivery of anterior shoulder. tendency of postpartum haemorrhage can be prevented by prophylactic intravenous Ergometrine 0.Third stage Because of prolongation of labour. Size of the baby Engagement of the head Amount of liquor . interference is indicated Per abdomen: the following conditions are assessed.Arrested occipito posterior position If there is failure to progress (arrest) in spite of good uterine contractions for about ½-1 hour after full dilatation of the cervix. Vaginal examination: the following conditions are to be noted. ischial spines. .e. side walls of the pelvis. sacro-coccygeal plateau. Station of the head Position of the sagittal suture and the occiput Degree of deflexion of the head Degree of moulding and caput formation Assessment of the pelvis at and below the level of obstruction i. pubic arch and transverse diameter of the outlet. 1. ARREST IN OCCIPITO-TRANSEVERSE OR OBLIQUE OCCIPITO POSTERIOR POSITION Ventous application Alternative methods Manual rotation followed by forceps extraction: The objectives are first to rotate the head manually until the occiput is placed behind the symphysis pubis and secondly in that position forceps blades are applied. The pelvis should be adequate. the baby is of average size and there is good amount of liquor. . Forceps rotation and extraction: In the hands of experts. Craniotomy . forceps rotation followed by extraction can be achieved by using Kielland forceps. Caesarean section: If the case is unsuitable for manual rotation specially in the presence of mid pelvic contraction. Its advantages over manual rotation are -No chance of displacement of the head -Aaccidental cord prolapsed is absent and rotation can be done at. caesarean section is much safer even at this stage. above or below the level of obstruction-depending upon the type of pelvis. 2. Liberal mediolateral episiotomy should be done. If the occiput remains at or above the level of ischial spines.OCCIPITO-SACRAL ARREST If the head is engaged and the occiput descends below the ischial spines. . forceps application in unrotated head followed by extraction as face to pubis is an effective procedure. caesarean section should be considered. Deep transverse arrest The head is deep into the cavity. the sagittal suture is placed in the transverse bispinous diameter and there is no progress in descent of the head even after ½-1 hour following full dilatation of the cervix. . flat sacrum and convergent side walls. Deflexion of the head Weak uterine contraction Laxity of the pelvic floor muscles.causes Faulty pelvic architecture such as prominent ischial spines. . .diagnosis The head is engaged The sagittal suture lies in the transverse bspinous diameter Anterior fontanelle is palpable Faulty pelvic architecture may be detected. caesarean section.management Based on fetal condition and pelvic assessment Vaginal delivery is found safe: following methods can be employed. Craniotomy in dead baby . Ventouse Manual rotation and application of forceps Forceps rotation and delivery with Kielland in the hands of an expert Vaginal delivery is not safe (with big baby and or inadequate pelvis). Manual rotation Whole hand method Half hand method . The corresponding hand is introduced into the vagina in a cone shaped manner after separating the labia by two fingers of the other hand . the right hand is usually used.Whole hand method Step.I (Gripping of the head): In ROP or ROT the left hand and in LOP or LOT. the head is rotated to bring the occiput the external hand form the flank to the midline. for anterior rotation of the head.Step-II (Rotation of the head): By a movement of pronation of the hand. . This is an essential prerequisite. A little over rotation is desirable anticipating slight recurrence of malpositon before the application of forceps. as such the right blade is introduced first and the left blade introduced underneath the right blade. it is placed on the right side of the pelvis after rotation.Step III: Application of the forceps: Following rotation. . when the right hand is placed on the left side of the pelvis. When the left hand is used. left blade of the forceps is introduced. the four fingers and not the thumb are introduced into the vagina. Its advantage over the whole hand method are Less space required Less chance to displacement of the head .2. Half hand method: In this method. In LOP and LOT positions. Thus. the fingers are placed posteriorly and the pressure is applied by the radial boarder of the hand. In ROP and ROT positions. . the pressure is applied on the side and parietal eminence of the head. The force is applied intermittently till the occiput is placed behind the symphysis pubis. the fingers are placed anterior to the head and the pressure is applied by the ulnar boarders of the hand.The rotation is done only by using the right hand. The four fingers are introduced into the vagina and tangnital pressure is applied on the head at the level of diameter of engagement. Nursing management Establish an IPR Collect history do the physical examination which includes abdominal examination. . vital signs and the vaginal examination to know the outcome. Changing position Detail explanation of situation and the possibilities Back massage to relieve the pain Maintain partograph Preparation for delivery Any deviations found must call a Doctor Family support must be given. Psychological support to the mother. Monitor the client throughout the labour carefully by monitoring FSH.