Abnormal Labour: Mal Presentation and Malposition
Abnormal Labour: Mal Presentation and Malposition
Abnormal Labour: Mal Presentation 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
• 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