MALPRESENTATION

And CORD PROLAPSE

 MALPRESENTATION
Malpresentation is the
situation where a fetus
within the uterus is in
any position that is not
cephalic
Etiologic factors in malpresentation
Fetal
 Maternal Prematurity
Great parity Multiple gestation
Pelvic tumors Hydramnios
Pelvic contracture Macrosomia
Uterine Hydrocephaly
malformation
Trisomies
Anencephaly
Myotonic dystrophy
Placenta previa
Breech Presentation
     
Introduction
Breech presentation occurs in 3-4% of all deliveries.
The occurrence of breech presentation decreases with
advancing gestational age. Breech presentation occurs in
25% of births that occur before 28 weeks’ gestation, in

7% of births that occur at 32 weeks, and 1-3% of births

that occur at term.
.

Perinatal mortality is increased 2- to 4-fold with breech

presentation, regardless of the mode of delivery. Deaths
most often are associated with malformations,
 Predisposing factors
 prematurity, uterine abnormalities
(eg, malformations, fibroids), fetal
abnormalities (eg, CNS
malformations, neck masses,
aneuploidy), and multiple
gestations.
AF abnormality.Abnormal
placentation.
Contracted pelvis.MG.Pelvic tumor.
 Perinatal mortality is
increased 2- to 4-fold with
breech presentation,
regardless of the mode of
delivery.
 Congenital malformation 6%
 Types of breeches

 Frank breech (50-70%) - Hips flexed,

knees extended
 Complete breech (5-10%) - Hips
flexed, knees flexed
 Footling or incomplete (10-30%) -
One or both hips extended, foot
presenting
 position
SA,SP,LST,RST

LSP,RSP.LSA,RSA
STATION
 DIAGNOSIS
Palpations and ballottement
Pelvic exam
X-ray studies
Ultrasound
 MANAGEMENT
Antepartum
During labor
Delivery
 Criteria for VD orCS
 VD  CS
Frank FW<1500or> 3500gr
GA>34w Footling
Small pelvis
FW=2000-3500gr Deflexed head
Adequate pelvis Arrest of labor
Flexed head GA24-34w
Nonviable fetus Elderly PG
No indication Inf or poor history
Fetal distress
Good progress labor
 VAGINAL BREECH DELIVERY
 Three types of
vaginal breech deliveries:
1.Spontaneous breech delivery
2.Assisted breech delivery
3.Total breech extraction
 Footling breech presentation
: Once the feet have delivered,
there may be temptation to pull
on the feet. However, this should
never be done with a singleton
gestation because it may
precipitate an entrapped head in
an incompletely dilated cervix or
it may precipitate nuchal arms.
As long as the fetal heart rate is
stable and no physical evidence
of a prolapsed cord exists,
expectant management may be
followed, awaiting full cervical
dilatation.
.
 Assisted vaginal breech delivery
 Thick meconium passage
is common as the breech
is squeezed through the
birth canal. This usually is
not associated with
meconium aspiration
because the meconium
passes out of the vagina
and does not mix with
the amniotic fluid.
  Picture 3. Assisted vaginal
breech delivery: The
Ritgen maneuver is
applied to take pressure
off the perineum during
vaginal delivery.
Episiotomies often are cut
for assisted vaginal
breech deliveries, even in
multiparous women, to

 
prevent soft-tissue
dystocia.
                             
 Picture 4. Assisted vaginal breech delivery:
No downward or outward traction is
applied to the fetus until the umbilicus has
been reached.
Picture 5. Assisted vaginal breech delivery: With a
towel wrapped around the fetal hips, gentle
downward and outward traction is applied in
conjunction with maternal expulsive efforts until the
scapula is reached. An assistant should be applying
gentle fundal pressure to keep the fetal head flexed.

                               
Picture 6. Assisted vaginal breech delivery: After
the scapula is reached, the fetus should be rotated
90° in order to delivery the anterior arm.

                               
Picture 7. Assisted vaginal breech delivery: The anterior
arm is followed to the elbow, and the arm is swept out of
the vagina.

                               
Picture 8. Assisted vaginal breech delivery: The fetus is
rotated 180°, and the contralateral arm is delivered in a
similar manner as the first. The infant is then rotated 90°
to the back-up position in preparation for delivery of the
head.

                               
Picture 9. Assisted vaginal breech delivery: The fetal head is
maintained in a flexed position by using the Mauriceau-Smellie-
Veit maneuver, which is performed by placing the index and
middle fingers over the maxillary prominence on either side of
the nose. The fetal body is supported in a neutral position with
care to not overextend the neck.

                               
Picture 10. Piper forceps application: Pipers are
specialized forceps used only for the aftercoming head of
a breech presentation. They are used to keep the head
flexed during extraction of the fetal head. An assistant is
needed to hold the infant while the operator gets on one
knee to apply the forceps from below.

                               
Picture 11. Assisted vaginal breech delivery: Low 1-minute Apgar scores are not
uncommon after a vaginal breech delivery. A pediatrician should be present for the
delivery in the event that neonatal resuscitation is needed.

                               
Picture 12. Assisted vaginal
breech delivery - The neonate
after birth

                              
 Risks

Lower Apgar scors

An entrapped head
Nuchal arms ,
Cervical spine injury
Cord prolapse
PROGNOSIS
 Table 1. Zatuchni-Andros Breech Scoring

Add 0 Points Add 1 Point Add 2 Points

Parity 0 1 2

Gestational age
39+ 38 <37
(wk)

EFW (lb) 8 7-8 <7

Previous breech 0 1 2

Dilatation 2 3 4

Station -3 -2 -1

If the score is 0-4, cesarean delivery is recommended

 VERSION
External
Internal
Internal podalic version
COMPOUND PRESENTATION

shoulder-dystocia.zip
 COMPLICATION SD

Immediate
neonatal;birth
asphyxia ,traumatic
injury
Maternal;PPH,lacerations
 SHOULDER
DYSTOCIA (Sh.D)
 Shoulder
dystocia
will still the
obstetric
nightmare
 Definition:
Shoulder dystocia (Sh. D) is the
inability to deliver the fetal
shoulders after delivery of the
head, without the aid of
specific maneuvers (ie. other
than gentle downward
traction on the head) .
 Definition
Objective definition :

Mean head-to-body
delivery time > 60
seconds
 PATHOPHYSIOLOGY
Shoulder dystocia results from
a size discrepancy between the
fetal shoulders and the pelvic inlet
when:
1. The bisacromial diameter is large
relative to the biparietal diameter
2. Pelvic prim is flat rather
than gynecoid

.
SHOULDER DYSTOCIA
 0.15-1.7%,
 Risk
factor;macrosomia,diabetes,histo
ry of SD,prolonged2th stage of
labor,maternal
obesity,multiparity,postterm.
 50%SDnorisk factor
 Sono
 Release techniques
Complications of Sh D

1.Maternal
2.Fetal
Maternal Complications (25%)

1. Postpartum hemorrhage 11%

2. Vaginal laceration 19%
3. Perineal tears 2nd&3rd 4%
4. Cervical laceration 2%
FetalRelease techniques
Complications of Sh D
Fetal Complications of Sh D
Brachial plexus injuries,
Fractures of the humerus, and
Fractures of the clavicle
are the most commonly reported
injuries associated with shoulder
dystocia
Fetal Complications of Sh D

Traction combined with

fundal pressure has been
associated with a high rate
of brachial plexus injuries
and fractures
Fetal Complications of Sh D
Fewer than 10% of
deliveries complicated by
shoulder dystocia will result
in a persistent brachial
plexus injury.
 Fetal Complications
Release techniques
Head –shoulder interval > 7min.

Brain injury
(sensitivity & specificity :70 %)
 With hypoxic fetus it is much shorter
Can shoulder
dystocia be
predicted ?
 RISK FACTORS FOR SHOULDER
DYSTOCIA
PRECONCEPTIONAL:
1. Maternal birth weight
2. Prior shoulder dystocia 12%
3. Prior macrosomia
4. Pre-existing diabetes
5. Obesity
6. Multiparity
7. Prior gestational diabetes
8. Advanced maternal age
 RISK FACTORS FOR SHOULDER
DYSTOCIA

Antenatal:
 Excessive maternal weight gain
 Macrosomia
 G. diabetes
 Short stature
 Post term
 RISK FACTORS FOR SHOULDER
DYSTOCIA
Intrapartum:
1. Protracted or arrested active phase
2. Protracted or failure of descent of
head
3. Need for midpelvic assisted delivery
 RISK FACTORS FOR SHOULDER
DYSTOCIA
Most of the prenatal and antenatal risk
factor are interrelated with fetal
macrosomia. So the main risk factor is:

Fetal
Macrosomia
MANAGEMENT
(Within5- 7 minutes)

.
 Management
1-Suprapubic pressure
2-McRobert manoeuver
3- Woods corkscrew .
4-Rubens manoeuver
5-Delivery of P. shoulder
6-Zavanelli
7-All fours
8-Cleidotomy
9-symphysiotomy
 ACOG Issues Guidelines
Recommendation 1991
1-Call for help: assistants,
anesthesiologist
2-Initial gentle attempt of
traction.
3-Generous episiotomy.
4-Suprapubic pressure.
 ACOG Issues Guidelines
Recommendation 1991
5-The Mc Roberts
manoeuvre
(Exaggerated hyper
flexion of the thighs
upon the abdomen.)
&
Suprapubic pressure
in the direction of the
Foetal face .
 McRoberts manoeuvre: X ray pelvimetry study

No increase in pelvic dimensions.

Decrease in the angle of pelvic inclination P=0.001
Straightening of the sacrum P= 0.04%
Tends to free the impacted anterior shoulder
Gherman et al Obstet Gynecol 95:43 ,2000
 ACOG Issues Guidelines
Recommendation 1991
If Mc Roberts failed:
6-Woods manoeuvre:
•The hand is placed
behind the posterior
shoulder of the fetus.
•The shoulder is
rotated progressively 180 d in a corkscrew manner so
that the impacted anterior shoulder is released. .
ACOG Issues Guidelines
Recommendation 1991

7-Delivery of the
posterior arm :
.
By inserting a hand
into the posterior
vagina and ventrally
rotating the arm at
the shoulder

delivery
over the
perineum
UMBILICAL CORD
PROLAPSE
 Umbilical Cord Prolapse
 Etiology
– 1-275 deliveries
 Classification
– Complete: cord is seen or palpated ahead of
presenting part (OB Emergency)
– Fundic: cord felt through intact membranes ahead of
presenting part
– Occult: hidden or not visible at any time during
course of labor
 Definition: umbilical cord that lies below/beside
presenting part
 Umbilical Cord Prolapse
 Precipitating factors:  Precipitating factors:
– Long umbilical cord – Amniotomy before
– Abnormal location on fetal head is engaged
placenta – IUPC placement
– Small or preterm – External cephalic
infant version
– Polyhydramnios
– Multiple gestation
 Umbilical Cord Prolapse
 Clinical Manifestations:
– Cord observed or palpated
– Bradycardia following ROM
– Repetitive, variable decelerations that do not
respond to medical intervention (e.g.
amnioinfusion)
– Prolonged decelerations (>15 bpm lasting 2
mins or longer yet <10 mins)
 Umbilical Cord Prolapse
 Nursing interventions:
– Assess fetal viability
– Call for assistance
– Relieve pressure from cord (usually presenting part)
 Continuous manual relief of pressure from presenting part
 Avoid excessive manipulation of cord
 Re-position client: Trendelenburg, modified Sim’s, or knee-
chest
 Prepare for emergency delivery
 Administer oxygen by mask 10-12 L/min
 Fill maternal bladder with 500-700 cc NS
 Continuous fetal monitoring
 Possible neonatal resuscitation (notify neonatal team per
hospital protocol)
 Umbilical Cord Prolapse

 Aim of Medical management:

– Immediate delivery of viable infant
– Hallmark treatment: C-section