Talaulikar 2012
Talaulikar 2012
Talaulikar 2012
Malpositions and percent of fetuses at term present with vertex. Other presenta-
tions (which are classified as malpresentations) include breech,
malpresentations of the fetal face, brow, shoulder or compound presentation. Vertex refers to
a diamond shaped area of the fetal head that is bounded by each
Introduction
Normal mechanism of labour involves a well flexed fetal head
that engages into maternal pelvis so that the occiput comes to lie
near one of the lateral aspects of maternal pelvis at the onset of
labour. As labour advances, progressive flexion and descent of
fetal head cause the occiput to rotate anteriorly when the head
reaches the pelvic floor. When this sequence of changes in the
position of fetal head is altered, a malposition or malpresentation
occurs. Malpositions or malpresentations of the fetal head are
usually diagnosed in labour and while in many cases vaginal
delivery is possible, they are associated with a more difficult
labour and increased operative interventions with attendant risks
to both the mother and the baby.
Definitions
The term ‘presentation’ refers to the part of the fetus which is
presenting to the pelvic inlet. It can also be defined as the part of
the fetus occupying the lower pole of the uterus. Nearly 95
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Figure 3 (a) Well flexed fetal head in vertex presentation, (b) deflexed head in a brow presentation and (c) extension of the fetal neck in a face
presentation.
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Different types of fetal head presentations, attitudes and anteroposterior diameters (transverse diameter is the
biparietal e 9.5 cm)
Presentation Attitude Anteroposterior diameter Length cm
Table 1
great care should be taken to avoid damaging the orbits which expressed as 1þ (apposition of the parietal bones at the suture
may be felt along with nose, mouth and malar bones. but no overlap), 2þ (overlap of parietal bones but reducible with
gentle pressure), 3þ (overlap of bones with difficulty in reducing
Signs of obstructed labour with gentle pressure).
The mother will be exhausted and show signs of dehydration
If the presenting part is too large for the pelvis, arrest of labour
such as tachycardia, pyrexia and oliguria. While in a primigravid
can occur. It is very important to be vigilant for signs of
woman, obstruction may be followed by the uterine inertia
obstructed labour and perform a timely operative delivery to
(weak or no contractions), in a multigravida the major risk is of
avoid adverse maternal or neonatal outcomes. Obstructed labour
violent uterine contractions leading to ruptured uterus.
is characterized by signs such as e arrest of cervical dilatation/
descent of fetal head, oedematous poorly applied cervix, Partogram
increasing caput and moulding, formation of Bandl’s ring which
may be visible or palpable per abdomen. Caput is a soft tissue Progress of labour should be closely monitored because slow
swelling of the fetal scalp and increase in its size with progress of progress of labour is the commonest manifestation of fetal
time is a subjective assessment. The degree of moulding is malpositions in labour. The partogram is a very useful tool which
can help in timely diagnosis and action for dystocia.
PS PS
Figure 4 Figure 5
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Occipitoposterior positions
PS PS PS
S S S
Figure 6
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Diagnosis
Face presentation is usually diagnosed during labour. On
abdominal palpation, a large amount of head is palpable on the
same side as the back without a cephalic prominence on the
same side as the limbs. In thin women, a sharp angulation may
be felt between the fetal occiput and back. Confirmation is
usually on vaginal examination when the orbits, nose, mouth
and malar bones are palpable. The fetal mouth sucking on the
examiner’s finger is a classical sign! It is important to distinguish
face from breech by remembering that the malar prominences
and mouth form a triangle, whereas the ischial tuberosities and
Figure 7 Face presentation. the anus form a straight line.
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Management
Malpresentations of fetal head such as face or brow are infre-
quently encountered and much of the practice recommendations
are derived from clinical experience and consensus of expert
opinion. When face presentation is diagnosed during labour, the
woman should be informed of the findings. She should be made
aware that there may be facial swelling and bruising noted in the
baby soon after delivery however it is likely to resolve without
any permanent damage over the next few days. Regular
abdominal and gentle vaginal examinations should be under-
taken to monitor progress while avoiding injury to fetal orbits/
face. If progress is good and the position is mentoanterior (or
rotating round to mentoanterior) then vaginal delivery can be
anticipated. If progress is slow or arrests, or if the position
remains mentoposterior, caesarean section is indicated. Fetal
blood sampling, use of a fetal scalp electrode and ventouse
delivery are contraindicated with a face presentation.
Figure 8 Brow presentation.
If the baby delivers vaginally, the fetal chin descends down
the symphysis pubis and the delivery of the head is completed by
flexion of the fetal neck bringing the occiput out last causing
considerable posterior perineal distension. In second stage with Diagnosis
failure to progress, a forceps delivery is possible although usually It is rare to diagnose brow presentation before onset of labour.
confined to non-rotational forceps when the mentum is anterior On abdominal examination much of the fetal head may be
and head is low. Before application of forceps, it is vital to palpable. On vaginal examination, the head has not descended
confirm that no head is palpable per abdomen as the vaginal below the ischial spines and the root of the nose, supraorbital
findings can be misleading (because the chin is in the pelvis and ridges and anterior fontanelle are palpable.
the occiput lies posteriorly). It is important to remember that ‘the
head is always higher than you think’ and if the sacral hollow Management
feels empty then forceps should not be applied as the occiput The brow discovered in early labour may flex or extend, and
must still be in the abdomen. The biparietal diameter is usually early recourse to caesarean section on this finding alone should
approximately 7 cm behind the advancing face so consequently, be avoided. Nonetheless one should be alert to the signs of
even when the face is distending the vulva, the biparietal obstructed labour, and preparations should be undertaken for
diameter has only just entered the pelvis. caesarean section and time allowed to see whether flexion or
Even with favourable mentolateral or mentoanterior position, extension takes place. Failure to progress in the next few hours in
if there is failure to progress the safer option for the fetus is labour with persistent brow indicates a caesarean section. In
caesarean section in the first stage. At caesarean section care extreme prematurity the fetus may descend as a brow and deliver
should be taken with delivery of the fetal head to avoid exten- as a brow or may convert to a face or vertex after it reaches the
sions of the uterine incision. pelvic floor. As with the face presentation, care is required when
undertaking caesarean section to avoid extensions to the inci-
Brow presentation sion. The aim should be to flex the head with the delivering hand
The incidence of brow is between 1 in 700 and 1 in 1500 before delivering it from the wound. A
deliveries.
Causes
Cephalopelvic disproportion FURTHER READING
Prematurity 1 Hunter S, Hofmeyr GJ, Kulier R. Hands and knees posture in late
In brow presentations, the head is deflexed and presents to the pregnancy or labour for fetal malposition (lateral or posterior).
pelvis with the largest anteroposterior diameter (Figure 8). Many Cochrane Database Syst Rev 2007 Oct 17. Issue 4. Art. No.:
brow presentations in early labour are transient proceeding to CD001063.
complete extension (face) or flexion (vertex) as labour 2 O’Driscoll K, Jackson RJ, Gallagher JT. Prevention of prolonged labour.
progresses. Br Med J 1969 May 24; 2: 477e80.
3 Akmal S, PatersoneBrown S. Malpositions and malpresentations of the
Mechanism fetal head. Obstet Gynaecol Reprod Med 2009; 19: 240e6.
The fetal head presents with its largest mentovertical diameter 4 Baskett TF, Calder AA, Arulkumaran S. Munro Kerr’s operative obstet-
(13 cm) to the maternal pelvis and vaginal delivery is not rics. In: Assisted vaginal delivery. 11th edn, vol. 8. Elsevier Ltd, 2007.
possible in an adequately grown term baby. Spontaneous 91e125.
conversion to either vertex or face presentation by flexion or 5 Sizer A, Nirmal D. Occipitoposterior position: associated factors and
further extension, respectively, may occur with advancing labour obstetric outcome in nulliparas. Obstet Gnaecol 2000; 96: 749e52.
especially if the fetus is small. part 1.
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