Abnormal Labour: Mal Presentation and Malposition

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Abnormal Labour

Mal presentation and Malposition


Definitions
• Fetal presentation describes the part of the fetus
which will enter through the cervix first. Normal
part is the vertex
• Fetal position is the orientation of the fetus
compared to the maternal body pelvis
• Malpresentation refers to any presentation other
than the vertex.
• Malpositions are abnormal positions of the vertex
of the foetal head relative to the maternal pelvis.
• Longitudinal presentations: Cephalic: head
down or Breech: bottom/feet down
• Transverse presentation: shoulder
• Compound presentation: an extremity
presents alongside the primary presenting
part
Risk Factors
• Multiparity – causes lax abdominal walls
• Prematurity – fetus is smaller
• Multiple pregnancy (twins)
• Abnormalities of the uterus, e.g. fibroids, Partial septate
uterus
• Foetal abnormalities e.g. hydrocephalus
• Placenta praevia – placenta covers the internal cervical os
• Amniotic fluid abnormalities – polyhydramnios and
oligohyadramnios
• History of malpresentation in previous pregnancy
Types of Malpresentation and malposition

1. Breech presentation
2. Compound presentation
3. Transverse lie and shoulder presentation
4. Face presentation
5. Brow presentation
6. Occipital posterior position
Epidemiology
• Breech presentation: 1 in 33 deliveries
• Face presentation: 1 in 600-800 deliveries
• Transverse lie: 1 in 833 deliveries
• Compound presentation: 1 in 1500 deliveries
• Brow presentation; 1 in 500 deliveries
OCCIPITO – POSTERIOR POSITION
• Defined as a vertex presentation with foetal back directed
posteriorly.
• Most common malposition, The incidence is 10% at onset of
labour.
• The occiput-posterior (OP) position results from a poorly
flexed vertex.
• In this case head initially engages normally but then the
occiput rotates posteriorly rather than anteriorly.
• It may occur as a result of a flat sacrum or weak uterine
contractions being unable to push the head down into the
pelvis with sufficient strength to produce the correct rotation.
• Typically it results in prolonged labour, foetal distress or
obstructed labour.
• When the occiput is placed over the right sacroiliac joint, the position is
called right occipito posterior (R.O.P) position
• When placed over the left sacro-iliac joint, is called left occipito posterior
(L.O.P) position.
• When it points towards the sacrum it is called direct occipito posterior
position
• Right occipito-posterior (ROP) is more common than left occipito-posterior
(LOP) because:
 The left oblique diameter is reduced by the presence of sigmoid colon.
 The right oblique diameter is slightly longer than the left one.
 Dextro-rotation of the uterus favours occipito-posterior in right
occipito-posterior position.
Occipito-posterior position is an abnormal position (malposition) of the
occiput rather than an abnormal presentation.
Causes
• The shape of the pelvis: anthropoid and
android pelvises are the most common cause
of occipito-posterior due to narrow fore-
pelvis.
• Maternal kyphosis: The convexity of the foetal
back fits with the concavity of the lumbar
kyphosis.
• Anterior insertion of the placenta
Other causes
• Placenta praevia,
• Pelvic tumours,
• Pendulous abdomen,
• Polyhydramnios,
• Multiple pregnancy.
Diagnosis
• Is diagnosed both during pregnancy and labour
During pregnancy
• Inspection:
• The abdomen looks flattened below the umbilicus due
to absence of round contour of the foetal back.
• A groove may be seen below the umbilicus
corresponding to the neck.
• Foetal movement may be detected near the middle line.
• The outline created by high, unengaged head can look
like a full bladder
Palpation
Fundal grip:
• The breech is felt as a soft, bulky, irregular non-ballotable mass.
Umbilical grip:
• The back felt with difficulty in the flank away from the middle line.
• The anterior shoulder is at least 3 inches from the middle line.
• The limbs are easily felt near, or on both sides, of the middle line.
First pelvic grip:
• The head is usually not engaged due to deflexion.
• The head is felt smaller and escapes easily from the palpating fingers as
they catch the bitemporal diameter instead of the biparietal diameter in
occipito-anterior.
Second pelvic grip:
• The head is usually deflexed.
Auscultation:
• FHS are heard in the flank away from the
middle line.
• In major degree of deflexion, the FHS may be
heard in middle line.
Comparison of abdominal contour in (A) posterior and (B) anterior
positions of the occiput
During labour
• In addition to the previous findings vaginal
examination reveals:
 The direction of the occiput.
 The degree of deflexion.
• The Anterior fontanelle (four radiating sutures/
diamond shaped) is easily felt towards the pubis.
• The posterior fontanelle (three radiating sutures)
may also be palpable towards the sacrum
Mechanism of Right occipitoposterior
position (long rotation)
• The lie is longitudinal
• The attitude of fetal head is deflexed
• The presentation is vertex
• The position is right occipitoposterior
• The denominator is the occiput
• The presenting part is the middle or anterior area of the
parietal bone
• The occipitofrontal diameter, 11.5 cm, 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
Flexion
• Descent takes place with increasing flexion. The
occiput becomes the leading part.
Internal rotation of the head
The occiput reaches the pelvic floor first and
rotates forwards 3/8 of a circle along the the right
side of the pelvis to lie under the symphysis
pubis. The shoulders follow, turning 2/8 of a circle
from the left to the right oblique diameter
Crowning
The occiput escapes under the symphysis pubis and
the head is crowned.
Extension
The sinciput, face and chin sweep the perineum and
the head is born by a movement of extension
Restitution
In restitution, the occiput turns 1/8 of a circle to the
right and the head realigns itself with the shoulders.
Internal rotation of the shoulders
The shoulders enter the pelvis in the right oblique diameter;
the anterior shoulder reaches the pelvic floor first and rotates
forwards 1/8 of a circle to lie under the symphysis pubis.
External rotation of the head
At the same time the occiput turns a further 1/8 of a circle to
the right
Lateral flexion
The anterior shoulder escapes under the symphysis pubis, the
posterior shoulder sweeps the perineum and the body is born
Factors favouring long anterior rotation

• Well flexed head


• Good uterine contractions.
• Roomy pelvis.
• Good pelvic floor.
• No premature rupture of membranes
Causes of failure of long anterior rotation

• Deflexed head.
• Uterine inertia.
• Contracted pelvis: rotation of the head cannot
easily occur in android pelvis due to projection
of the ischial spines and convergence of the
side walls.
• Lax or rigid pelvic floor.
• Premature rupture of membranes or its rupture
early in labour.
Possible course and outcomes of labour

1. Long internal rotation


This is the commonest outcome.
With good uterine contractions producing
flexion and descent of the head, the occiput will
rotate forward 3/8 of a circle as described
above.
2. Short internal rotation
• Persistent occipitoposteriro position means
that the occiput fails to rotate forwards.
• Instead, the sinciput reaches the pelvic floor
first and rotates forwards.
• This results to the occiput going into the
hollow of the sacrum.
• The baby is born facing the pubic bone (face
to pubis)
Cause
• This is caused by failure of flexion
• The head descends without increased flexion
and the sinciput becomes the leading part.
• It reaches the pelvic floor first and rotates
forwards to lie under the symphysis pubis
Diagnosis
1st stage of labour
Signs include;
Deflexed head
Fetal heart heard in the flank or in the midline
The descent is low
Second stage of labour
• Delay is common
• Vaginal examination will reveal the anterior fontanelle felt
behind the symphysis pubis. However, this may be masked
by a large caput succedaneum.
• If the pinna of the ear is felt pointing towards the woman’s
sacrum, this indicates a posterior position.
• The long occipitofrontal diameter causes considerable
dilatation of the anus and gaping of the vagina while the
fetal head is barely visible, and the broad biparietal
diameter distends the perineum and may cause excessive
bulging
• As the head advances, the anterior fontanelle
can be felt just behind the symphysis pubis.
• Consequently,the fetus is born facing the
pubis
• Characteristic upward moulding is present
with the caput succedaneum on the anterior
part of the parietal bone
The birth
• The sinciput will first emerge from under the symphysis
pubis as far as the root of the nose and the midwife
maintains flexion by restraining it from escaping further
than the glabella, allowing the occiput to sweep the
perineum and be born
• The head is then extended by grasping it and bringing the
face down from under the symphysis pubis.
• Perineal trauma is common and one should watch for signs
of rupture in the centre of the perineum (button hole tear)
• An episiotomy may be required, owing to the larger
presenting diameters
Undiagnosed face to pubis
• If the signs are not reconized at an earlier
stage, the midwife may first be aware that the
occiput is posterior when the hairless
forehead is seen escaping beneath the pubic
arch.
• Any accidental extension of the fetal head
should be corrected by flexion towards the
symphysis pubis
Deep transverse arrest
• The head descends with some increase in
flexion.
• The occiput reaches the pelvic floor and begins
to rotate forwards
• Flexion is not maintained and the
occipitofrontal diameter becomes caught at the
narrow bispinuous diameter of the outlet
• Arrest may be due to weak contractions, a
straight sacrum or a narrowed pelvic outlet
• The sagittal suture is found in the transverse diameter
of the pelvis and both fontanelles are palpable
• Neither sinciput nor occiput leads
• The head is deep in the pelvic cavity at the level of the
ischial spines although the caput may be lower still
• Obstetric assistance is required as there is no advance
• Manual rotation may be attempted first, and then
vaginal birth may follow with the woman’s effort
Management
• Inform mother and spouse and let them
participate in decisions
• Encourage sigh out slowly breathing as
pushing may not resolve the problem
• Change of position may help overcome the
urge to bear down
• Delivery might be performed by either
vacuum extraction or caesarian section
Management of labour
First stage
• Exclude contracted pelvis.
• Exclude presentation or prolapse of the cord.
• Inertia and prolonged labour are expected so oxytocin may be
indicated unless there is contraindication.
• Contractions are sustained, irregular and accompanied by marked
backache which needs analgesia as pethidine or epidural analgesia.
• Avoid premature rupture of membranes by: -
 Bed rest,
 No straining,
 Avoiding high enema,
 Minimizing vaginal examinations.
• The other management and observations as in normal labour.
Second stage of labour
• Wait for 60-90 minutes. During this period:
 Observe the mother and foetus carefully.
 Combat inertia by oxytocin unless it is contraindicated.
Contraindications of oxytocin:
 Disproportion.
 Incoordinate uterine action.
 Uterine scar e.g. previous C.S, hysterotomy,
myomectomy, metroplasty or previous perforation.
 Grand multipara.
 Foetal distress.
• One of the following will occur:
1. Long internal rotation 3/8 circle:
• Occurs in about 90% of cases and delivery is completed as in
normal labour.
2. Direct occipito-posterior (face to pubis):
• Occurs in about 6% of cases.
• The head can be delivered spontaneously or by aid of outlet
forceps.
• Episiotomy is done to avoid perineal laceration.
3. Deep transverse arrest (1%) and persistent occipito-posterior (3%):
• The labour is obstructed and one of the following should be done:
Vacuum extraction or caesarian section
Vacuum extraction (ventouse):
• Proper application as near as possible to the occiput will promote
flexion of the head.
• Traction will guide the head into the pelvis till it meets the pelvic floor
where it will rotate.
Manual rotation and extraction by forceps:
• Under general anaesthesia the following steps are done:
 Disimpaction: the head is grasped bitemporally and pushed slightly upwards.
 Flexion of the head.
 Rotation of the occiput anteriorly by the right hand vaginally aided by:
 Rotation of the anterior shoulder abdominally towards the middle line by the
left hand or an assistant.
• Fix the head abdominally by an assistant, apply forceps and extract it.
Caesarean section;
• It is indicated in Failure of the above methods.
• Other indications for CS are:
Contracted pelvis
Placenta Praevia
Prolapsed pulsating cord before full cervical
dilatation,
Elderly primigravida.
Craniotomy can be done: If the foetus is dead.
Complications of OPP
• Obstructed labour
• Maternal trauma;
 increased risk of obstetric anal sphincter injury
(OASIS)
 Third or fourth degree tears
• Neonatal trauma;
 Intracranial haemorrhage
 Cerebral haemorrhage may also result from chronic
hypoxia that accompanies prolonged labour

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