2. MALPRESENTATION
DEFINITION: Any presentation other then
cephalic is malpresentation. Normally In 95%
cases its cephalic presentation.
LIE: Its relation of long axis of fetus to long axis
of mother( longitudnal, transverse and oblique).
PRESENTATION: Its leading part of fetus that
comes in direct contact with maternal pelvis(
cephalic, breech, shoulder).
TYPES OF MALPRESENTATION:
1) Breech………. 3 to 4%.
2) transverse……. < 1%.
3) Oblique……… < 1%.
3. 1) BREECH
DEFINITION:
When lie is longitudnal but fetal buttocks are in
contact with maternal pelvis.
INCIDENCE: 3 TO 4%.
TYPES:
i) Frank or extended breech
ii) Flexed breech or complete breech.
iii) Footling breech.
5. RISK FACTORS FOR BREECH
MATERNAL FETAL PLACENTAL
Poly and Oligo Fetal anomaly like
hydrocephalus
Placenta previa
Multiparity
CPD Muscular deformity Short umbilical cord
Congenital uterine
abnormalities like
unicornate, bicornate,
septate uterus.
Twin
Fibroid uterus Prematurity
Large ovarian mass
6. SIGNIFICANCE OF BREECH
PRESENTATION
Nothing wrong to mother and fetus during antenatal
period.
As incidence of breech up to 6 month is
……....40%.
by 7 month
is……….20%.
by 8 month…………15%.
At TERM……………3 TO
4 %.
Significance is with MODE of delivery.
EL. LSCS;
MOTHER; Increase surgical trauma to mother.
FETUS; Fetus at low risk.
DELIVERY;
MOTHER; Mortality increase.
7. RISKS TO MOTHER AND FETUS
MATERNAL FETAL
Prolong labour Fracture of bones
Operative delivery Asphyxia
Trauma during maneuvers Intra cranial hemorrhage, head
entrapment during head delivery
PPH Brachial plexus injury.
Infection Cord prolapse … footling… 17%
extended….0.5%
flexed…….…5%.
8. MODE OF DELIVERY
During antenatal period around 37 weeks,
selecting suitable candidates for ECV and
Vaginal breech delivery and explaining them
cons and pros of procedure, can be given
options of:
I) ECV
II) VAGINAL BREECH DELIVERY.
III) ELECTIVE LSCS.
9. A…..EXTERNAL CEPHALIC VERSION(
ECV)
DEFINITION;
The fetus is turned to cephalic position by
manipulating through maternal abdominal wall.
Success rate; 50 to 80 %.
Suitability for procedure;
Single fetus, abnormality of fetus and uterus
ruled out, liquor adequate, placenta upper, baby
weight between 2.5 to 3.5kg, breech should be
extended of flexed, breech should not be engaged
in maternal pelvis , neck attitude is flexed, no
previous scar on uterus, previous normal delivery,
CPD rule out, no IUGR baby.
10. TECHNIQUE FOR ECV
After selecting suitable patient, written informed
consent is taken.
PRE-REQUISITE; It should be done
1) In a setup where senior Obstetrician, Anesthetist
and Pediatrician is available.
2) Blood is arranged. Theater is available.
3) Continuous CTG facility is available.
4) Drugs like tocolytics available.
5) Steroid cover should be in- cooperated in mother.
BEST TIME; 37 to 38 weeks.
12. Post ECV Care:
Do CTG, Give anti D if RH negative
patient is, see for any vaginal profuse discharge or
bleeding, any uterine contractions.
If all went ok explain patient about normal
symptoms and sign of labour and to keep check
on fetal movements. In any emergency report to
labour room , otherwise routine antenatal care
schedule advised to mother.
Rest as she comes in labour things will be
managed as in cephalic presentation labour.
13. B…… VAGINAL BREECH DELIVERY
TYPES;
I) Spontaneous breech delivery.
II) Assisted breech delivery.
III) Extracted breech delivery( only in 2nd twin
breech).
CONTRA-INDICATIONS:
All opposite of indications of ECV and BREECH
VAGINAL DELIVERY , i.e
placenta previa, twin, previous scarred uterus,
CPD, oligo or poly, primigravida, footling breech,
extended head, hydrocephalus fetus , IUGR,
macrosomia,recurrent APH episodes, fibroid uterus,
uterine anomalies.
14. When to deliver: wait for spontaneous onset of labour.
2 ) In Assisted delivery;
1st STAGE OF LABOUR;
Once in labour, its been managed as in cephalic
presentation like pain relief, bladder empty, CTG,
partograph.
MECHANISM:1) Here denominator is sacrum instead of
occiput,
Bi-Trochantaric diameter which enters pelvic inlet is 9.8
cm equalant to Bi-Parietal diameter in cephalic
presentation. Buttocks enter in left Sacro-transverse
diameter which is
left Occipito-tanseverse in cephalic presentation.
2) With contractions buttocks descent….leading to lateral
flexion at lumbar vertebrae….making INTERNAL
ROTATION of buttocks ….so now Bi-trochanteric diameter
is anteroposterior at pelvic outlet.
So as in Cephalic presentation baby in Breech too had
redirected itself to adjust to largest diameters of pelvic
15. 2nd STAGE of labour:
HANDS-OFF TEHNIQUE; As buttocks are
visible at perineum.. Let baby deliver at its own, if
episiotomy require give it, as sacrum visible
delivery legs of baby. If legs Flexed they will deliver
at its own. If legs Extended have to do PINARD’S
MANOEUVERE.
Loosen umbilical cord…keep back of baby
ALWAYS anterior…once scapula is visible .
ARM DELIVERY; If Flexed arms they will easily be
delivered. In Extended arms do LOVESET’S
MANOUVER.
HEAD DELIVERY;
1) BURN MARSHAL TECHNIQUE.
2)MAURICEAU- SMELLIE-VEIT
MANOEUVRE.
16. THIRD STAGE; Is managed as in routine.
Baby handed over to pediatrician. Episiotomy
stitched.
All events should be DOCUMENTED.
Post Delivery Care; As in usual delivery.
Breast feeding advised.
Contraception.
24. 2) TRANSVERSE
MALPRESENTATION
DEFINITION;
When long axis of fetus lies perpendicular to
long axis of mother. In this case shoulder is most
likely the presenting part.
INCIDENCE; 0.3 T0 LESS THE 1%.
TYPES; i) Dorso-anterior ii) Dorso-posterior.
ETIOLOGY; Is same as in case of breech but
multipatiry is most common cause.
PRESENTATION;
Fundal height is less then gestational age. Lower
pole of uterus EMPTY. Head in right or left lumbar
region. Fetal heart will be heard in lumbar regions.
25. COMPLICATIONS: If goes in labour and that remain
neglected;
1) FETAL: Cord prolapse, hand and shoulder
prolapse, asphyxia and STILLBIRTH.
2) MOTHER: Prolong labour, uterine rupture,
operative delivery.
MODE OF DELIVERY:
VERY EARLY GESTATION; can be delivered
vaginally.
AT TERM;
Not in LABOUR …do ECV…cephalic
…induce.
27. 3 ) OBLIQUE MALPRESENTATION
DEFINITION;
When long axis of fetus lies at 45 degree to long
axis of mother. Here head is in right or left ILIAC
REGION.
INCIDENCE; 0.3 to < 1%.
TYPES; i) right ii) left oblique.
ETIOLOGY;
Same as in breech. Multiparity is most common
like that in transverse lie.
PRESENTATION:
Fundal height is same as gestation, Lower pole
empty. Presenting part felt in right or left iliac
region. Fetal heart are auscultated more on lateral
sites of maternal abdomen.
28. COMPLICATIONS; If goes in labour and remain
neglected
FETUS; cord prolapse, asphyxia and still birth.
MOTHER; with fetal compromise increase risk of
operative deliveries.
MODE OF DELIVERY:
VERY EARLY PREGNANCY; can be delivered
vaginally.
AT TERM;
NOT in labour….ECV…induce…vaginal
delivery.
In labour…….LSCS.
