MALPOSITION & MALPRESENTATION

Definition

.......Lie,...........Presentation,......is the denominator

Incidence

-Malposition: O.P 20%, ROP 18% & LOP 2%. (why?)

-Malpresentation: -Face 1/200

-Brow 1/2000

-Shoulder : 1/200

-Breech: At 28 weeks = 35%, At F.T 3.5%

Positions

	O.P	Face	Brow	Shoulder	Breech
First - LA	......	R.M.P	L.F.A	*L.Sc.A	*L.S.A
Second-RA	.........	L.M.P	R.F.A	*R.Sc.A	*R.S..A
Third- RP	*R.O.P	*L.M.A	R.F.P	R.Sc.P	R.S.P
Fourth-LP	L.O.P	R.M.A	L.F.P	L.Sc.P	L.S.P

'*' Denotes the commonest positions.Note that Sc.A & S.A positions are common so that the concavity of the fetus fits into the convesity of maternal lordosis.

Aetiology

I)Faults in the passage:

1-Contracted pelvis:

-Android & Anthropoid pelvis are the commonest cause of OP

-Flat pelvis turns OP to 2ry face (Comonest cause of face)

-CP is not a cause of breech, only association in 15% of cases.

2.Vertebral column abnormalities:

-Kyphosis=>OP due to opposition of maternal & fetal spines.

3.Soft tissue abnormalities:

-Fibroid uterus.

-CUMF : Septate uterus=>Transverse lie [shoulder]

Bicornuate uterus=>Breech

II)Faults in the passenger:

1.Fetal causes:

-Prematurity is the commonest cause of breech presentation.

-Multiple pregnancy

-IUFD

-CFMF: -Hydrocephalus=> Breech

-Anencephaly & neck tumours=>face.

2.Abnormal placental inssertion:

-Fundal=>Transversse lie

-Cornual=>Breech

-Anterior insertion=>OP[The fetus faces the placenta]

-Placenta previa=>Transverse lie

3.Liqour abnormalities: Oligohydramnious or polyhydramnious.

4.Umbilical cord abnormalities: Short or long UC

III)Faults in the powers: Lax abdominal wall muscles & uterus.

[Commonest cause of transverse lie]

IV)Idiopathic

CLINICAL PICTURE

SYMPTOMS

History & Symptoms:

-Previous accidents,poliomyelitis,rickets,limbing,....

-Obstetric history of previous malpresentation

-Abdominal enlargment: Small=>Frank breech

Small&from side to side=>Transverse lie.

-FK: -Felt on one side =>Dorsoanterior position

-Felt on both sides =>Dorsoposterior position.

-In breech presentation a hard tender swelling is felt in the upper abd.

Examination & Signs:

General examination :

-Stature , Gait ,Examniation of the back & lower limbs.

Abdominal examination

Inspection:

-Abdominal enlargment: Longitudinal or transverse

-Fetal movement on one or both sides.

-Presence of grooves:

Subumb. groove in OP & MP

Supraumb.groove in SP

Palpation:

-Fundal level : = Amenorrhea = Longitudinal lie

< Amenorrhea = Transverse lie or frank breech

-Fundal Grip :

*Breech occupies the fundus =>Cephalic presentation

*Head occupies the fundus => Breech presentation

*Empty =>Transverse lie = Shoulder presenttation

Head: Small,Hard,Regular,Tender,+ve ballotment

Breech: Large,Soft,Irregular,Not tender, No ballotment.

-Umbilical grip:

*Back to one side ,Limbs on the other => Dorsoanterior position

*Limbs on both sides=>Dorsopoosterior position

*Back on both sides=> Frank breech ,as the splinted limb is mistaken

for a back [smooth,regular,no Knobs]

*Head to one side, breech on the other =>Shoulder presentation.

-First pelvic grip:

*Breech = Breech presentation

*Empty = Shoulder presentation

*Head = Cephalic presentation =>

Occipitopost.	Face presentation		Brow present.
	Mentoanterior	Mentoposterior
Small receeding head.	Horse shoe structure is felt	Occiput felt higher than sinciput	Occiput & sinciput felt at the same level

-Second pelvic grip:

Non engagment of the presenting part .Except in cases of frank breech.

Auscultation of FHS:see diagram

*Above umb.=Breech/ *Below umb.=Ceph/*At umb.=Shoulder or Frank Br.

*To the Right or left according to position

*Near umb. = anterior position/*Away from umb.= posterior position

Investigations

1.U/S

2.Pelvimetry

B/During labor

Exactly as durin pregnancy,In addition P/V examination is done and will show:

1-Early in labor:

-Uterine inertia resulting in slow cervical dilatation

-Prolonged first stage.

-Abnormally tense bag of forewaters

-Early ROM

-Risk of cord prolapse.

2.Late in labor the presenting part is felt:

OP=>Posterior fontanelle directed posteriorly

Face=>2Maxilla,Chin, mouth known by suckling

Breech=>2ischial tuberosities,sacrum ,anus known by meconium

Shoulder=>acromion,clavicle&humerus+axilla Known by ribs.

Hand: No Heel,long mobile fingers,thumb at different line

Foot: Heel,short fingers all at same line with limited mobility

Elbow:Pointed ,no patella

Knee: Flat with patella

Brow: Chin is not felt

Mechanism of labor

1.X-Y diameter descends and engages in the oblique diameter of the pelvic inlet.

2.Increased flexion in OP, or increased extension in face.

3.X meets the pelvic floor & rotates anteriorly:

*1/8 of a circle if X is anterior

*3/8 if X is posterior = Long internal rotation

Now the position is D.X.A

4.X hinges below the SP & Y delivers then X

Problems of the mechanism of labor {Overview}

Step 1: May not occur due to

-Large diameter of the PP as in Brow [Mento-vertical 13.5 cm]

-Absence of a PP as in Shoulder presentation

Step 2: Deflexion in OP & incomplete extension in MP .

Step 3: Failure of long anterior rotation in OP & MP Leads to:

-POP or PMP = no mechanism for both

-DTA = No mechanism for both

-DOP or DMP= DOP delivers as face to pubis, DMP no mechanism

Long internal rotation fails to occur due to:

1.CP,Soft tissue obstruction

2.Macrosomia,drained liqour, Deflexed head in OP or incomplete extension in face (O/M meet PF then S [DTA] or O/M&S meeet PF together [POP or PMP]or S meets PF first=>Posterior rotation of O/M [DOP orDMP]

3.Uterine inertia.

Step 4: Failure of exit

-DMP hinges by the sinciput and cannot deliver the submentum as the head is fully extended

Managment

During pregnancy:............................[ECV for tr.lie]

During labor

Managment of the first stage:

-Guard against uterine inertia by:

-Avoid heavy sedation

-Wise use of ecbolics

-Evacuation of the UB & rectum

-Guard against ROM by:

-Patient rest.

-Avoid excess P/V examination

-No Bearing down

-Guard against infection by:

-Avoid ROM

-Avoid excess P/V

-Antibiotics if ROM occurs.

-Once ROM occurs P/V & Auscultation to FHS are done to exclude cord prolapse

-Strict intrapartum monitoring of labor.

Managment of the second stage: {Overview}

Wait for 2hrs in PG or 1 hr in MG if there is a mechanism for labor.

*Then Correct the abnormal mech:

Step 1 : C.S is the safest. Alternatively IPV may be done for shoulder presentation

Step 3:

Rotation may be tried for OP by:

Manual rotation + Forceps extraction

Forceps rotation + Forceps extraction

Ventouse extraction.

Step 4 : C.S

.................................

*If dead fetus destructive operation is done.[to be avoided in neglected shoulder]

.................................

Indications for CS:

1.Passage of the action line on partogram during the first stage

2.Nonengament

3.Failure of rotational techniques [Some advice CS for MP with failed long internal rotation].

-The fetus is carefully examined for CFMF or traumatic injuries

Managment of the third stage:

-Afterbirth is delivered either by consrvative or active method & carefully examined for retained parts or torn membranes

Managment of the fourth stage:

-Careful fundoperineal examination is carried out if rotation or version was attempted.

-Any tears or lacerations are carefully repaired.

-Sterile vulval pad is applied and the patient transferred to the recovery room under frequent massage of the uterus and observation of the vital data.

Complications

A/Maternal:

1.Uterine inertia due o nonengagment

2.Prolonged labor

3.Maternal & fetal distress

4.Obstructed labor & rupture of the uterus

5.Early ROM

6.Cord Prolapse

7.Chorioamnionitis

8.Postpartum hemorrhage :Atonic or traumatic

9.Puerperal sepsis :Prolonged labor, instrumental delivery

B/Fetal:

1.Asphyxia from prolonged labor

2.Fetal injuries

3.Associated CFMF.

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