Malpresentation and
malposition:
introduction
• A malpresentation is one where the fetal head is
presenting but not as well flexed vertex with the
occiput in the anterior quadrant . A
malpresentation include position where the
head is not the presenting part.
• malposition: abnormal placement of the part of
body.
• malpresentation :abnormal position of the fetus
in the birth canal.
Con=
• Causes of malpresentation:
Types of pelvis .
Polyhydramenouerous
Multipara ( lax uterus muscle).
Multiple pregnancy.
Placenta previa.
Pelvic tumor.
Hydrocephalous.
Uterine fibroid.
Occipitoposterior position
introduction
• In approximately one tenth of all laobours , the fetal position is
posterior rather than anterior .
• Def:
the occiput is directly diagonally and posteriorly (ROP , LOP).
• In these position , during internal routation , the fetal head must
routate not through 90 arc but through 135 arc.
Occiput posterior is most common fetal malposition.
When the is the occiput posterior the occiput of fetal head is direct to
word the back of maternal pelvis .
During labor 87% op fetus rotate to and occiput anterior
OPP suggested by :
Dysfunctional labor:
Prolong active phase .
Arrest decent.
Con=
Sever back pain: from compression of the fetus head on the sacrum.
examination
Abdominal ex:
Slight flattening in the lower abd observe .
Limps easily felt.
Pv:
Anterior fontanel can be felt behind the symphesis pubis.
Clinical therapy;-
Close monitoring of and fetal status and labor progress to determine
whether the vaginal or cs is the safer method.
-cs birth is chosen if maternal or fetal problem make vaginal birth un
wise or if CPD is present
-forceps can be used to deliver the fetus while it is still in the occiput
posterior position or to rotate the occiput to and anterior position
(called scanzoni s maneuver) .
labour
• In 70% of cases routation spontaneously , in 10%
short routation will occure.
• Uterine contraction may be ineffective because poor
flexion of the head .
• Molding is poor.
Management:
First stage of labour :
as normal case .
nothing to correct the position in this stage.
apply heat or cold compress.
Con=
Management of second stage of labor :
if there is strong contraction , good expulsive efforts
normal delivery take place .
The indication of interference:
failure of presenting part to descent.
fetal distress.
maternal distress.
uterine distochia .
IV glucose solution to restore energy.
Manual rotation .
Forceps delivery.
Caesarian section.
Complication
• Maternal distress.
• Fetal distress.
• Perennial laceration.
• Intracranial hemorrhage.
nursing managment
Nursing assessment and diagnosis:
Assessment may reveal depression in the maternal abdomen above the
symphysis
FHR is typically heart far laterally on the abdomen
On vaginal examintion physician find the diamond shaped anterior
fontanelle in the anterior portion of the pelvis
Nursing diagnosis that may apply
include ;-
-acute pain related to back dis comfort secondary to opp
-ineffective individual coping related to un anti cipatated dis comfort
and slow progress in labor.
planning and implementation;-
Changing maternal position to enhance rotation
Of op or occiput transverse
-knee chest position provide down word slant to vaginal canal direct
the fetal head down word
on desend
-women may try pelvic rocking .the stroking begin the fetal back and
swing around thother side of the abdomen After -
After the fetus has rotated the woman lie sim position on the side
opposite the fetal back.
Breech presentation
• It occurs in about 3% of labor.
• Def: the fetal presenting part is the buttocks.
• The exact cause of breech presentation is unknown .
• It occur in about 3% to 4% of labours .
• Associated with preterm birth , placenta previa , multigestation ,
uterine anomalies , and fetal anomalies (anencephaly and
hydrocephaly ) .
Types:-
• 1- frank breech .
• 2-incomple breech .
• 3- complete breech .
Con=
• Types:
Frank breech ( extended ):both hips are flexed and knees extended.
Flex breech(complete) : the legs are flexed at both hips & knees.
Balf breech : one leg drown down through the cervix , & the other leg
extended at the knee .
Con=
• Diagnosis:
During pregnancy :
Fetal head in the funds .
FHS is heard in higher part than in cephalic .
( slightly above maternal umbilica).
U\S.
During labor : PV ex.
Clinical therapy :-
• Convert breech presentation to cephalic
presentation prior to beginning of labor .
• External cephalic version (ECV) may be attempted .
• Best method of birth ???
Con=
• Mechanism of labor :
Normally : lateral flexion of the body.
External cephalic version : check the FHR after the procedure .
Groin traction with extended leg after episiotomy .
Risk of beech presentation :-
Maternal implication :-
• Cesarean birth .
Fetal-neonatal implication :-
• Increased risk of prolapsed cord , lea to …..
• Increased risk of cervical cord injuries
• Increased risk of traumatic injury to the after coming
head .
Con=
• Complication:
Fetal anoxia ( from prolapsed cord ).
Traumatic injury to the after coming head .
Fracture of the spine or arm.
Dysfunctional labor.
NURSING MANAGEMENT :-
• ASSESSMENT :-
During pregnancy :
Fetal head in the funds .
FHS is heard in higher part than in cephalic .
( slightly above maternal umbilica).
U\S.
During labor : PV ex.
BROW PRESENTATION :-
• In brow presentation , the forehead of the fetus is
the presenting part .
• Occur more often in multiparas than in nulliparas
due to lax abdominal and pelvic musculature .
• It is the least common types of abnormal
presentation .
• The largest diameter of fetal head (approximately
13.5 cm ) .
RISK OF BROW PRESENTATION :-
• Increase maternal risk of :-
- longer labour due to ineffective contraction an slow
or arrest fetal descent .
- cesarean birth if brow presentation persist .
• Fetal-neonatal risks include :-
- cerebral an neck compression .
- damage to the trachea and larynx .
- edema , bruising .
NURSING ASSESSMENT :-
A brow presentation can be detected on vaginal
examination (with x-ray or U/S ) , by palpating of the
diamond shape anterior fontanelle on one side and
orbital ridge and root of the nose on the other side .
Face presentation
• Fetal head presenting in different angle called
asynclitism.
• In face presentation the face is the presenting part .
• The fetal head is hyperextended .
• The incidence of face presentation is about 1 in 600 birth .
• The anterior posterior diameter is 9.5 cm .
It suggested by :
Abdominal examination :
head & back are felt on the same side of the
uterus .
The back is difficult to out line because it is
concave.
FHS in the side of feet & arm can be palpable .
PV: nose , mouth & chin felt.
Sonography.
Risk of face presentation :
Maternal risk include :-
• Increase risk of CPD and prolongation of labor.
• Increase risk of infection .
• Cesarean birth if chin (mentum) is posterior .
Fetal-neonatal risk include :-
• Cephalhematoma .
• Edema of the face and throat .
• Pronounced molding of the head .
Con=
• Labor :
If the chin anterior : NVD.
If the chin posterior : cesarean section are require .
Complication :
Facial edema .
Lip edema ( the baby can not sucking well).
the baby transmit to intensive nursery , observed for 24
hr ,reassurance parents .
CLINICAL THERAPY :-
• Vaginal birth if : no CPD is present , the mentum is
anterior and the labor pattern is effective .
• Many mentum posterior presentation spontaneously
convert to anterior in last stages of labor .
• If mentum remains posterior , a vaginal birth is not
possible and cesarean birth is necessary .
Shoulder presentation
• Def : the baby lie with its long axis transveres or oblique in the
uterus ( the shoulder is usually the presenting part ).
• Occur in approximately 1 in 300 term birth .
Con=
• Diagnosis :
Can be observe on inspection ( horizontal abdomen).
Sonogram
Clinical therapy :-
According to gestational age .
Con=
• Labor :
On this position the baby can not deliver normally.
When the membrane rupture cesarean birth
indicated .
• Complication :
Cord prolapsed .
Arm prolapsed .
Shoulder block the cervix .
COMPOUND PRESENTATION :-
A compound presentation is one in which there are two
presenting parts such as the occiput and fetal hand , or
the complete breech and fetal hand .
Most compound presentations resolve themselves
spontaneously , but others required additional
manipulation on birth .
