Malpositions and Malpresentations

Introduction
Baby presents itself in the mothers pelvis in any

position other than the vertex presentation -

abnormal presentation, or malpresentation.

Abnormal - because -higher risk of obstruction

and other birth complications than the vertex

presentation. Contd

 The normal way for a baby to deliver -vertex with

the occiput lying anteriorly.

Cephalic presentation-if the occiput is not lateral

in early labour or anterior in advanced labour then a malposition exists. Contd

 If the leading pole of the foetus is anything other

than the vertex, a malpresentation exists.

Malpositions and malpresentations present in

labour can proceed to normal during delivery.

More difficult labour is common Operative delivery & risk is high for both.

Contd

 Left and right occipito-anterior are the only

normal presentations and positions.

Malposition: occipito-posterior.
Malpresentations: anything except vertex.
Contd

 Malpresentations are

Face presentation, Brow presentation,

Breech presentation,
Shoulder presentation,

Cord presentation and

Complex presentations.

Malposition: OccipitoPosterior

1. Introduction
Most common type of malposition of the occiput. A persistent occipitoposterior position (POP)

results from a failure of internal rotation prior to birth.

In Occipito-Posterior - The vertex is presenting,

but the occiput lies in the posterior rather than the anterior part of the pelvis.

2. Definition
In a vertex presentation where the occiput is

placed posteriorly over the sacro iliac joint or directly over the sacrum, it is called an occipito posterior position

3. Incidence
- 10% of all vertex presentations - Expected more during late pregnancy and much less

in late second stage of labour.

- Early in labour(10-20%)

- Late in labour(1-2%)
Contd

- ROP is 5 times more common than the LOP

- Dextro rotation of the uterus

- Presence of sigmoid colon on the left- Diminished

left oblique diameter -disfavor LOP position.

- The right oblique diameter is slightly longer than

the left one.

4. Types
ROP

LOP
DOP POP

Primary: It occur late in pregnancy before the

onset of labour. It occur in association with anthropoid pelvis. Secondary: It develops during labour and in association with android pelvis

ROP

LOP

4. Types
Primary: It occur late in pregnancy before the

onset of labour. It occur in association with anthropoid pelvis.

Secondary: It develops during labour and in

association with android pelvis

5. Causes
Not clear

The shape of the pelvic inlet: (50-85%)

anthropoid and android pelvises are the most

common cause - due to narrow fore-pelvis &

roomier hind pelvis
Others(15%)
High pelvic inclination
Contd

 Abnormal uterine contraction Maternal kyphosis: The convexity of the fetal

back fits with the concavity of the lumbar kyphosis.

Anterior insertion of the placenta Fetal factors: Marked deflection of the fetal

head.

Contd

 Reasons for deflexion of head

High pelvic inclination Attachment of the placenta on the anterior wall of the uterus Primary brachy-cephaly
Contd

 Other causes of Malpresentation:

Placenta praevia,

Pelvic tumours,
Pendulous abdomen, Polyhydramnios, Multiple pregnancy. - Idiopathic(10-30%)

6. Risk factors for OP position at delivery include

Nulliparity
Maternal age greater than 35 years

Obesity
African-American race Previous OP delivery
Contd

6. Risk factors for OP position at delivery include

Decreased pelvic outlet capacity
Gestational age 41 weeks

Birth weight 4000 g

Prolonged first and/or second stage of labor

7. Diagnosis
Antenatal diagnosis
Diagnosis during labour

Imaging

Contd

A. Antenatal diagnosis
i.

Listen to the mother

examination Inspection

ii. Abdominal

Palpation and Auscultation

iii. Antenatal preparation

Contd

i. Listen to the mother

Complain of backache
She may feel that her babys bottom is very

high up against her ribs.

Reports - feeling movements across both sides

of her abdomen.
Contd

ii. Abdominal examination Inspection Palpation and Auscultation

Inspection
The abdomen looks flat, below the umbilicus. saucer-shaped depression at or just below the

umbilicus-dip between the head and the lower

limbs of the fetus.
Contd

a. Inspection
The

outline
by the

created

high, unengaged head like bladder. can a look full

Comparison of abnormal contour in posterior (1) and anterior positions (2) of the occiput

b. Palpation
ON PALPATION:

- The breech is easily palpated at the fundus, - The back is difficult to palpate as it is out of

maternal side and almost adjacent to the maternal spine.

- Limbs can be felt on both side of midline
Contd

b. Palpation
- High head reason for non engagement in Primi

gravida

large

presenting

diameter,

the

occipitofrontal (11.5cm) The occiput and sinciput are on the same level. Flexion allows the engagement of the suboccipitofrontal diameter (10cm).
Contd

Engaging diameter of a deflexed head, OF 13.5cm

Flexion with Descent of the head

b. Palpation
Umbilical grip: The findings are:

1.The fetal limbs are more easily felt near the

midline on either side. 2.The fetal back is felt away from the midline on the flank and often difficult to outline clearly. 3.The anterior shoulder lies far away from the midline.
Contd

b. Palpation
Umbilical grip: The findings are:

1.The fetal limbs are more easily felt near the

midline on either side. 2.The fetal back is felt away from the midline on the flank and often difficult to outline clearly. 3.The anterior shoulder lies far away from the midline.
Contd

b. Palpation
Pelvic grips: The findings are:

1. The head is not encaged.

2. The cephalic prominence (Sinciput) is not felt as prominent as found in well flexed occipitoanterior. In direct occipito-posterior, the small sinciput is confused with breech.
Contd

b. Palpation
The cause of the deflexion

Is a straightening of the fetal spine against the

lumbar curve of the maternal spine. This makes the fetus straighten its neck and adopt a more erect attitude.

ON AUSCULTATION:

- F.H.S can be heard at

midline. - Sometime f.H.S can be heard more easily at the flank on the same side of the back. - Difficult to locate specially in lop

iii. Antenatal preparation

Active changes of maternal posture. Mother adopting a kneechest position several

times a day - temporary rotation of the fetus to an anterior position - short-term effect upon fetal presentation.

B. Diagnosis during labour

Head is high
Non engagement of head

May complain of continuous and severe

backache worsening with contractions

B. Diagnosis during labour

Large

and

irregularly

shaped

presenting

circumference - membranes tend to rupture spontaneously at an early stage of labour

Contractions may be incoordinate.

B. Diagnosis during labour

Good contractions but slow descending of the

head.
Strong desire to push early in labour because the

occiput is pressing on the rectum.

Presenting dimensions of a deflexed head

Vaginal examination
The findings will depend upon the degree of

flexion of the head.

Anterior fontanelle in the anterior part of the

pelvis - difficult if caput succedaneum is present.

The direction of the sagittal suture and location

of

the

posterior

fontanelle

confirms

the

diagnosis.

Contd

 The findings in early labour are: Elongated bag of membranes - rupture during

examination.
The sagittal suture occupies any of the oblique

diameters of the pelvis.

 Posterior fontanelle is felt near the sacro iliac

joint.
The anterior fontanelle is felt more easily

because of the deflexion of the head and at times, is felt at a lower level than the posterior one.

 In late labour diagnosis is often difficult - caput formation

which obliterates the sutures and fontanelles.

In such cases, the ear is to be located and the

unfolded pinna points towards the occiput.

Simultaneous assessment of the pelvis should be

done.

c. Imaging
Ultrasonagraphy is rarely done.
It is helpful to know the descent, attitude of

the head and its relation to the pelvic walls

(position).

8. Mechanism of (labour) Right occipitoposterior position (long rotation)

The head encages through the

right oblique diameter in ROP and left oblique in LOP.

The encaging transverse diameter of the head is

biparietal (9.5cm)
Contd

8. Mechanism of (labour) Right occipitoposterior position (long rotation)

Antero-posterior diameter is either

Suboccipito-frontal (10cm) or

Occipito-frontal

(11.5cm)

(deflexion

engagement is delayed).
In favorable circumstances of OPP - mechanism

is possible.

Contd

Fetal Description/Criteria:

The lie is longitudinal

The attitude of the head is deflexed

The presentation is vertex

The position is right occipitoposterior

The denominator is the occiput

Contd

Fetal Description/Criteria:

The presenting part is the middle or anterior area

of the left parietal bone

The occipitofrontal diameter, 11.5cm, lies in the

right oblique diameter of the pelvic brim.

The occiput points to the right sacroiliac joint

and the sinciput to the left iliopectineal eminence.
Contd

Mechanism of labour
The main movements are:
Flexion

Internal rotation of the head

Crowning

Extension
Restitution

Internal rotation of the shoulders

External rotation of the head

Lateral flexion

Crowning: Occiput escape under the pubic

arch and the head is said to be crown

Alternative mechanism in favorable situation (uncommon)

If the shoulders fail to follow the anterior rotation

of the occiput,
The neck sustains a torsion and the shoulders

remain static in the left oblique diameter in ROP

and in the right oblique diameter in LOP.

 In such cases Restitution occurs 3/8th of a circle and

External rotation occurs through 1/8th of a circle

in the opposite direction of restitution.

However the mechanism is quite unlikely.

 In OP Presentation

Favorable circumstances 90%

Unfavorable circumstances 10%

In unfavorable circumstances of OPP

In Certain circumstances

The occiput fails to rotate as described

previously.

 The causes of faulty rotation

Deflexion of the head, Weak uterine contraction, Faulty shape of the pelvis - flat sacrum, prominent ischial spines or convergent side walls and weak pelvic floor muscles. Big baby and immobility of the fetal trunk The drainage of liquor amnii.

Incomplete forward rotation

Sinciput & occiput touch the pelvic floor simultaneously

Malrotation - Sinciput anterior rotation - occiput to the sacral hollow Occipito- sacral position

Results in Deep transverse arrest

Oblique posterior arrest

Favorable circumstances

Unfavorable circumstances

Face to pubis

Occipito-sacral arrest

Mechanism of Face to Pubis delivery

Further descent occurs
Flexion occurs

Restitution
External rotation

Persistent occipito-posterior
Abnormal mechanism of the occipito- posterior

position.
Delivery - spontaneously as face to-pubis or

occipito- sacral arrest.

Deflexed head, Faulty shape of pelvis, Weak pelvic floor muscles, Big baby, Immobility of fetal trunk, Drainage of AF

Incomplete forward rotation

Sinciput & occiput touch the pelvic floor simultaneously

Malrotation - Sinciput anterior rotation - occiput to the sacral hollow

COURSE OF LABOUR/ CARE IN LABOUR

Course of events in labour are modified
Longer first and second stage

Painful labour
The deflexed head not fit well onto the cervix -

does not produce optimal stimulation for uterine contractions

First stage
Tendency to delay means longer time of first

stage.
Causes are
Persistence of deflexion of the head

1. Delay in engagement
alignment

Driving force fetal axis not in

2. Membrane status -

Deflexed head - cannot fit well in spherical lower segment - loss of ball valve action - uterine contraction - EROM and drainage of liquor. ill fitting in the LUS -lack of stimulus for uterine contraction- results slow dilatation of the cervix. Pressure on the rectum by wide occiput - premature desire of bearing down effort in 1st stage. Exhaustion of client.

3. Uterine contraction-

The woman may experience

Severe and unremitting backache, causes tiring -

very demoralizing because of slow progress.

Midwife support essential for mother and her

partner to cope with the labour.

The

all-fours

position

may

relieve

some

discomfort.

 Prolonged

labour

prevent

the

mothers

dehydration or ketosis.
Incoordinate

uterine

action

or

ineffective

contractions correct an oxytocin infusion.

The woman may experience a strong urge to

push before full dilation causes cervix edema delay onset of 2nd stage.

 The urge to push eased by - change in position,

use of breathing techniques or inhalational

analgesia - enhances relaxation.
Partner/midwife can assist throughout labour

with massage, physical support and suggestions

for alternative methods of pain relief.

Pain control methods.

Second stage
Delayed 2nd stage - long internal rotation or

malrotation / arrest of the head.

This may happen in android pelvis or in mid

pelvic or in mid pelvic contraction.

If felt uncared - arrest of the head may lead to

obstructed labour.

 Confirm full dilatation of the cervix -

moulding and caput succedaneum may

bring the vertex into view.

Onset of 2nd stage no visible head -

encourage the woman to remain uprightshorten the length of the second stage and may reduce the need for operative delivery.

Third stage
Increased incidence of

Postpartum hemorrhage and

Trauma of the genital tract

MODE OF DELIVERY
Long anterior rotation of the occiput - SVD or

AVD.
Short posterior rotation - SVD or AVD and

perineal injuries
Non- rotation or short anterior rotation SVD.

Uncared - prolonged and obstructed labour. Trauma to the genital tract

MODE OF DELIVERY
Moulding - compression of the OF diameter with

elongation

of

the

vault.

Frontal

bones

displacement beneath the parietal bones tentorial tear.

MODE OF DELIVERY
Prognosis

Maternal morbidity (4 out of 5 cases no

trouble),

Incidental to prolonged labour and operative

delivery.

Increased perinatal morbidity and mortality asphyxia or trauma during vaginal operative delivery.

MANAGEMENT OF LABOUR
Principle in the management of the OPP are

1) Early diagnosis,

2) Strict vigilance with watchful expectancy

3) Judicious and timely interference, if necessary.

 Diagnosis and evaluation:

Fetal back on the flank - F.H.S not easily

located,
Early ROM should arouse suspicion. Internal examination is confirmatory. Overall assessment of the client and The pelvic assessment is mandatory.

 Early Caesarean Section

OPP is not an indication of caesarean section.

CS for Pelvic inadequacy or its unfavorable

configuration,
Obstetric complications - pre-eclampsia, post

caesarean pregnancy, big baby usually need caesarean section.

 First stage Allow for normal labour in uncomplicated cases. The following are the special instructions: Anticipating prolonged labour- IV RL.

Judge progress of labour

Observe for a triad - Weak pain, persistence of

deflexion and non-rotation of the occiput

Indication of caesarean section

 Judge Progress of Labour

(a) Progressive descent of the head

(b) Rotation of the back and the anterior shoulder

towards the midline

(c) Increasing flexion of the head
(d) Position of the sagittal suture on vaginal

examination and
(e) Cervical dilatation.

 Weak pain, persistence of deflexion and non-

rotation of the occiput are the triad

coexistent - oxytocin infusion for augmentation

of labour.
Indication of caesarean section

(a) Arrest of labour (failure of rotation)

(b) Incoordinated uterine action

(c) Fetal distress.

 Second Stage
In majority anterior rotation of the occiput is

completed and
The delivery is either spontaneous or

By low forceps or ventouse.

 Second stage: In minority

(Unrotated & Malrotated)

Good fetal and maternal conditions - a watchful

expectancy.
In occipito-sacral position, spontaneous delivery

as face- to pubis may occur. In such cases, Proper conduction of delivery and Liberal episiotomy- to prevent complete perineal tear.

 Third Stage
Prolongation of labour - Tendency of PPH

Prophylactic IV ergometrine 0.25 mg - delivery

of anterior shoulder.
Meticulous inspection of the cervix and lower

genital tract to detect any injury.

Arrested Occipito-posterior Position

Good uterine contractions for about 1/2-1 hour +

full dilatation of the cervix = if no progress interference is indicated.

Once more to be assessed - abdominal and

vaginal before suitable method of interference.

Types of arrested OPP transverse, oblique,

sacral

 Per abdomen: Assess:

(1) Size of the baby (2) Engagement of the head (3) Amount of liquor

(4) F.H.S.

 Vaginal examination: Note

(1)Station of the head

(2) Position of the sagittal suture and the occiput

(3) Degree of deflexion of the head

(4) Degree of moulding and caput formation

(5) Assessment of the pelvis at and below the level of obstruction.

ARREST IN OCCIPITOTRNSVERSE OR OBLIQUE O. P. POSITION

Ventouse (Vacuum extraction)
Alternative methods:

Manual rotation followed extraction. Forceps rotation and extraction Caesarean section Craniotomy

by

forceps

 Head engaged

OCCIPITO-SACRAL ARREST

Occiput descends below the ischial spines,

Forceps application in unrotated head followed

by

extraction

as

face-to-pubis

effective

procedure.
Liberal mediolateral episiotomy.
If occiput remains at or above the level of ischial

spines - caesarean section.

DEEP TRANSVERSE ARREST (DTA)

The head is deep into the cavity
Sagittal suture - transverse bispinous diameter

No progress in descent of the head even after 1/2-

1 hour following full dilation of the cervix.

 Arrest in occipito-transverse position - end result

of incomplete anterior rotation (1/8th of circle) of

oblique occipito-posterior position.

or it may be due to
Non-rotation of the commonly primary occipito-

transverse position of normal mechanism of labour.

Causes of DTA
(a) Faulty pelvic architecture (b) Deflexion of the head (c) Weak uterine contraction (d) Laxity of the pelvic floor muscles.

Diagnosis of DTA
(a) The head is engaged
(b) The sagittal suture lies in the transverse

bispinous diameter
(c) Anterior fontanelle is palpable

(d) Faulty pelvic architecture

Management
The fetal condition and pelvic assessment -

guide as to the line of management

Vaginal delivery is found safe (1) Ventouse- ideal (2) Manual rotation and application of forceps

Management
(3) Forceps rotation and delivery - Kielland / expert (4) Vaginal delivery is not safe - with big baby and or inadequate pelvis - Caesarean Section (5) Craniotomy in dead baby.

MANUAL ROTATION
Whole hand method or With half hand method Patient - in lithotomy position and GA Strict aseptic technique Catheterize the bladder Vaginal examination and detect the direction of

occiput if caput seek help of unfolded pinna

MANUAL ROTATION Whole hand method

Step- I: Gripping of the head
Step-II: Rotation of the head

Step-III: Application of the forceps

Step- I: Gripping of the head

R.O.P. or R.O.T. - Left hand and L.O.P. or L.O.T. - Right hand Separate the labia by two fingers Introduce the corresponding hand into the vagina

in a cone shaped manner.

Step- I: Gripping of the head

Occipito-transverse

position - the four fingers

are pushed in the sacral

hollow to be placed over the

posterior parietal bone and

the thumb is placed over the

anterior parietal bone.

Step- I: Gripping of the head

In

oblique

posterior

position - the four fingers

of partially supinated hand

are placed over the occiput

and the thumb is placed

over the sinciput.

Step-II: Rotation of the head

Slight

dis-impaction

needed for good grip.

By

a movement of

pronation of the hand,

rotate the head to bring

the
along

occiput
the

anterior
shortest

route.

Step-II: Rotation of the head

Simultaneously, the back of the fetus is rotated

by the external hand from the flank to the midline - essential prerequisite.
A little over rotation is desirable anticipating

slight recurrence of malposition before the application of forceps.

 If right hand is placed on the left side of the

Step-III: Application of the forceps

pelvis introduce left blade.

In left hand use - place right side of the pelvis.

While introducing the blades, - assistant fixes the

head by suprapubic pressure - first pelvic grip.

As it is a mid forceps application, axis traction

device should be used.

Difficulties and dangers

1) Failure to grip the head

2) Failure to dislodge the head from the impacted

position

3) Inadequate anesthesia
4) Wrong case selection.
Dangers- accidental slipping of the head above the

pelvic brim and prolapsed of the cord.

HALF HAND METHOD

Four fingers are only introduced in to the vagina. Advantages i) Less space is required and ii) Less chance to displacement of the head

Steps
The rotation is done only by using the right hand. With four fingers tangential pressure is applied

on the head at the level of diameter of

engagement.
Pressure is applied on the side and the parietal

eminence of the head.

Steps
In R.O.P. or R.O.T. position the fingers are

placed anterior to the head and the pressure is

applied by the ulnar border of the hand.
In L.O.P. or L.O.T. position, the fingers are

placed posteriorly and the pressure is applied intermittently till the occiput is placed behind the symphysis pubis.

Complications
PROM in early labour.

Cord presentation and prolapse Prolonged & obstructed labour Maternal, neonatal trauma rupture of uterus, PPH,

Puerperal sepsis & Cerebral hemorrhage

Increased incidence of perinatal mortality. Increased incidence of instrumental and operative

delivery.

Possible Nursing Diagnosis

Acute pain related to

progress of labor. Anxiety RT slow progress of labour Alteration in fetal tissue perfusion related to maternal position, epidural, oxytocin, rupture of membranes

Potential for infection

related to rupture of membranes

 Bibliography - Fraser

and

Cooper.

Myles

textbook

of

midwives.14th

edition.churchill

livingstone

publication.philadelphia2007. page no 551-557

- Dutta D.C. Text book of obstetrics.6th edition.

New central book publication. kolkata 2006. page no 365-374