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Current Practice

OBSTETRICS IN GENERAL PRACTICE


Management of Malpresentations in Obstetrics
ALAN D. H. BROWNE,* M.D., M.A.O., F.R.C.P.I., F.R.C.O.G.; DESMOND CARNEYt MB., B.CH., B.A.O., L.M.
This article is written by an obstetrical specialist in
collaboration with a general practitioner colleague. It represents a combined effort to present a synoptic view of
malpresentations encountered in obstetrics with a synthesis
of opinion on their management.

Normal Presentation
The normal situation in primiparae is confirmed by the
presence of a longitudinal foetal lie, a flexed foetal attitude,
and a.cephalic presentation as a vertex. The foetus forms
an ovoid with the larger breech and flexed lower limbs
occupying the roomier upper pole of the uterus, and the
heavier head lying over the pelvic brim.
This situation
should be present at 34 weeks, and should continue unchanged
until term. The head should become engaged at about 36
weeks' gestation, and should remain engaged until the onset
of labour.
In multiparae the longitudinal lie, attitude of flexion, and
vertex presentation should be present, as in the case of primiparae, and indeed the head should engage about the same
time. However, it is accepted that the head in multiparous
cases frequently remains free until the onset of labour through
laxity of the abdominal muscles altering the relationship
between the uterine and pelvic axes. Prior to its engagement,
however, it should be possible to push the head into the pelvic
cavity, either by posturing the patient by placing her in a
sitting position, or by pushing the head into the brim by
manual pressure as advocated in the external Muller test.

Abnormal Cephalic Presentations

Occipito-posterior Presentation
This malpresentation often causes trouble because it is
difficult to diagnose and is relatively frequent (about 7%) in
occurrence. It tends to be associated with an android type
of pelvis, in which the capacity of the fore-pelvis is reduced
by convergent bony contours, leaving more room in the
posterior segment for accommodation of the foetal occiput.
However, in some cases it probably has some connexion with
the attitude of the foetal head, which is held slightly extended.
In cases of occipito-posterior presentation engagement of
the head is typically delayed until labour is established. Postmaturity is commonplace owing to absence of the presenting
part in the lower segment. The onset of labour is frequently
preceded by rupture of the membranes. This is followed by
a gradual onset of uncoordinated uterine contractions,
irregular in rhythm, amplitude, and contraction pattern as
*
Master, Rotunda Hospital, Dublin.
t General Practitioner, Dublin.

revealed by tocographic studies. Progress is slow and


unpredictable, and the whole pattern of labour is strikingly
abnormal. The occiput may either rotate backwards to be
followed by delivery as a " persistent occipito-posterior," or it
may rotate forwards in the pelvic cavity, to be delivered in
the normal occipito-anterior position. The long forward
rotation of the occiput is a tedious affair, trying the patience
of all concerned. Nevertheless, although progress may be
painfully slow, it is correct to leave patients for as long as
possible without undue interference in the circumstances, provided that the condition of the foetus warrants such a course.
In almost 70% of cases, however, the occiput rotates forwards until the sagittal suture comes to lie in the transverse
diameter of the pelvic cavity. The head descends to the level
of the ischial spines, and there becomes arrested.
This
situation is known as " deep transverse arrest."
Further
advance is unlikely, and intervention to rotate the head and
effect delivery is essential.
In the management of this situation two movements are
necessary; firstly, further flexion of the head, which is commonly in a slightly extended attitude; and secondly, rotation
of the flexed head. This manoeuvre may be carried out by
manual rotation, which is perhaps the safest way. The main
disadvantage of this method is the tendency for the operator
to displace the head upwards, thus exposing the patient to the
risk of cord prolapse. Upward displacement is almost
inevitable where the head fits tightly in the pelvis, or where
the obstetrician has a large hand. This difficulty can be
avoided by the use of Kielland's forceps, which are specially
designed for cephalic application, and for rotation of the head
without upward displacement. Nevertheless these instruments
are fairly difficult to use and require considerable experience
before they can be used with confidence and safety. More
recently the vacuum extractor has proved beneficial in this
situation, more by its ability to secure full flexion of the head
than by its ability to effect rotation, during which movement
it tends to slip off.
The patient and her medical attendant must be prepared
for a prolonged period of labour when the occipito-posterior
position is present. Provided that the uterus acts normally,
and that the medical attendant can assure himself that progress is in fact taking place, there is much to be said for
conducting the case in home surroundings where the patient
will retain her confidence and morale more readily than
following transfer to hospital as an " emergency " case.

Face Presentation
Where the foetus is in an extended attitude, the normal
relationship of the foetal presenting part to the maternal pelvis
is upset. A fully extended attitude of the foetal head constitutes a face presentation, and the foetal body is in an
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Malpresentations-Browne and Carney

attitude resembling opisthotonus. In this position the head


generally passes through the pelvis without difficulty, the
chin being in the anterior position. Rotation takes place
because of interaction between the opposed contours of
mother and foetus, and the foetal head is born in a mentoanterior position. Delivery is generally a straightforward
affair, but if second stage delay or foetal distress demand
intervention it is safe and practical to deliver the baby by
application of forceps in the same way as if the head were
in an occipito-anterior position. About 60% of face presentations are associated with foetal abnormalities involving
anencephaly. About 30% are associated with normal infants
and appear to be due to abnormal extensor tone in the foetal
musculature alone, as described by Rydberg,l Vartan,' and
others. Approximately 10% are due to disproportion, with
contracted pelvis as a prominent cause.

Brow Presentation
In this situation the foetal head is held erect midway
between flexion and extension. The foetus appears to be, as
it were, too proud to permit easy delivery by mere application
of forceps and suchlike methods, and it either has to be fetched
out by caesarean section, or by being converted by flexion to
the more submissive attitude of vertex presentation, provided
that the cervix is sufficiently dilated to admit the whole hand
to effect this manceuvre. If conversion to a vertex presentation fails, it is sometimes possible to extend the head from
the " military attitude " of brow, into the flamenco-like attitude
of extreme extension resembling face presentation. Basically
these are complex manceuvres which must be carried out under
deep anaesthesia with a considerable degree of uterine relaxation. The names of Schatz and Thorn are associated with
methods in which the foetal occiput is cupped in the obstetrician's hand and flexion is then produced. The difficulty always
lies in maintaining the head in its new attitude. In recent years
the vacuum extractor has proved to be a very useful method of
maintaining the attitude of flexion following correction of brow
presentation by one of the manceuvres outlined above.
When it is realized that brow presentation is often foetal in
origin, and is generally to be regarded as only a single
episode in what will otherwise be a normal obstetrical career,
it will be appreciated that it is worth while dealing with the
situation by correction of the brow presentation and subsequent vaginal delivery. This is done by assessment of the
pelvic capacity by clinical examination supplemented if
necessary by x-ray pelvimetry. If disproportion can be
excluded (and this is the general rule), then the obstetrician
should lean towards achieving correction of the malpresentation and subsequent vaginal delivery.

Unstable Lie
Unstable lie may be usefully defined as " instability of the
longitudinal axis of the foetus in relation to that of the uterus
after the 36th week of gestation." This is a situation fraught
with dangers. To appreciate these it is well to consider the
associated causative factors first:
1.
2.
3.
4.

Disproportion
Placenta praevia
Hydramnios
Hydrocephalus

5. Pelvic tumours
6. Congenital abnormalities of the uterus
7. Pendulous abdomen, with abnormal relationship
between the axis of the uterus and the pelvis.
Analysis of a series of unstable lies at the Rotunda

Hospital showed that approximately 70% had association with

Bmnyn
MEDICAL
JOURNAL

grand multiparity and lax abdominal muscles alone. However 30% had association with serious factors, such as
placenta praevia and contracted pelvis. The latter was some-

times due to acquired spondylolisthesis, with forwarddislocation of the lumbosacral articulation, and consequent
reduction in the conjugate vera as described by Feeney.:'
Thus it becomes a matter of great importance to assess the
situation with the utmost care before the possible time of
onset of labour, bearing in mind the following unpleasant list
of dangers which may complicate unstable lie.
(a) Ante-partum haemorrhage from placenta praevia
(b) Obstructed labour due to disproportion, pelvic tumour,
or

hydrocephalus
(c) Premature rupture of membranes with consequent

risk of:
i Cord prolapse
ii Shoulder presentation
iii Neglected shoulder presentation, prolapsed arm,
and moulding of the uterus round the foetal body,
leading to intrauterine death and threatened rupture
of the uterus
In the face of this formidable situation many obstetricians
feel that there is little justification for withholding caesarean
section, and they would be right in most cases, although it is
sometimes difficult to embark on such a course with a patient
who has already had numerous normal deliveries and then
had a pregnancy complicated by unstable lie for no obvious
reason.
Nevertheless facts show that foetal salvage is
improved in this condition by using caesarean section more
freely, and this is the tendency at the present time. It is
obvious that this situation is quite unsuitable for management
as a domiciliary problem, and the sooner it is referred to a
maternity unit the better.

Prolapse of Cord

Cord Complications

Cord complications may occur in association with translie, hydramnios, or breech presentation. They may also
appear for no apparent reason. Prolapse of the cord spells
drama and danger in midwifery practice, and constitutes a
very grave emergency.
Management is divided into two
main phases : (a) first aid; and (b) replacement of the cord
and delivery.
First-aid management consists in endeavouring to relieve
pressure upon the cord, and thus to allow the continued survival of the foetus. This can be achieved in several bizarre
ways, such as the knee-chest position or the Trendelenburg
position, or simply by inserting a hand into the vagina and
preventing the presenting part from pressing on the cord.
None of these methods is of much use for more than a short
time while preparations for active and decisive delivery are
being made. However, one or other of them must be carried
out, and probably the knee-chest position is the most effective
of the three.
Immediate delivery by forceps application may be possible
where the cervix is fully dilated. Replacement of the cord
followed by application of the vacuum extractor to bring the
presenting part firmly on to the cervix is a satisfactory form
of management where the patient is advancing well in labour
with the cervix three to four fingers dilated.
Caesarean
section is the only choice where the cervix is less than three
fingers dilated, and indeed it might with justification be. used
for every case where immediate vaginal delivery is not considered possible.
Prolapse of the cord in the course of home confinement
often spells disaster for the foetus. Improvisation with the
first-aid methods described above is all that can be done in
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16 May 1964

Malpresentations-Browne and Carney

the patient's home unless immediate vaginal delivery following cord replacement is considered possible. It is important
not to attempt over-heroic measures such as internal version,
which places the mother in considerable danger without at
the same time doing anything significant to improve the
situation for the foetus.

Cord Presentation
Cord presentation implies that the cord presents within the
intact sac of membranes. All the horrors of cord prolapse
are impending. The cervix is usually only about two fingers
dilated at the time of diagnosis, and there is little choice apart
from caesarean section.

Breech Presentation
In primiparae the foetus generally assumes an attitude of
extension when a breech presentation occurs and it seems
probable that the malpresentation is due mainly to the
abnormal attitude of the foetus. This also makes external
version difficult at any time, especially after 34 weeks' gestation. Other factors associated with breech presentation in
the primipara include contracted pelvis, placenta praevia,
pelvic tumours, and congenital abnormalities of the uterus.
In the multipara, however, breech presentation is usually
transient, and in these cases the baby is generally in an attitude
of flexion. One good kick with the legs will cause a forward
somersault which restores a normal presentation. This
happens spontaneously in many cases and it is recognized as
such by the patient herself. External version is generally
quite easy at 34 weeks, and up to 37 or 38 weeks it may still
be worth attempting. It is more likely that a breech presentation in a multipara is associated with some significant factor
such as placenta praevia than in the case of a primipara.

Management
The main point of management in the primiparous breech
patient is the meticulous assessment of her pelvic capacity by
all available means, including clinical assessment using the
Muller-Munro Kerr technique, and x-ray pelvimetry in
selected cases. The general practitioner should avail himself
of the services of his specialist colleague for this purpose. In
vertex presentation, the head acts as the pelvimeter par
excellence, and reliance can be placed on the fact that if the
head engages in the pelvic brim it will pass through the pelvic
cavity in nearly every case. Where the breech presents in a
primipara this valuable sign is not available, and her medical
adviser has to exercise all available science and art in order
to assure himself that the pelvis is of adequate capacity to
transmit the average-sized baby, bearing in mind the penalty
of being stuck at the time of delivery with a baby whose legs
and trunk are delivered but whose head is immovably jammed
in a contracted pelvis. Such a situation should be impossible
in modern times, and indeed would be impossible were it not
for the negligence of patients who fail to attend their doctors,
or of doctors who fail to attend adequately to their patients.
Where the pelvic capacity is in doubt, caesarean section may
well be the method of choice for delivery, consideration also
being given to the patient's age and years of marriage before
conception, and other such relevant factors.
Trial labour in a breech case has little to recommend it.
The progress of the breech through the pelvic cavity is not
a reliable index of the capacity of the pelvis to transmit the
after-coming head. Symphysiotomy performed in order to
enlarge the pelvic cavity during delivery of a breech case is
theoretically attractive, coupled with a trial of labour. In

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1297

practice however it tends to be a panic-stricken situation with


great potentialities for danger to mother and child. Prophylactic symphysiotomy done before the onset of labour has a very
occasional place in carefully selected cases of breech presentation in young primigravidae with " borderline " pelvic contraction. The selection of such cases however requires highly
developed clinical judgment and meticulous assessment of the
pelvic capacity, and would be beyond the scope of general
practice.

Phases in Breech Delivery


There are three phases in breech delivery-delivery of the
legs; delivery of the arms; and delivery of the head.

Delivery of the Legs


In most primiparous breech cases the legs are extended and
the arms are folded. The frank breech acts as a good dilator
of the cervix and pelvic floor and labour proceeds along
normal lines. When the presenting part begins to distend
the perineum in the second stage delivery should be assisted
by performing a liberal episiotomy using local anaesthetic.
Every effort should be made to encourage the patient to
deliver the breech and as much of the trunk as possible by
her own expulsive efforts until it is an easy matter for the
medical attendant to disengage the legs. Traction should be
avoided at this stage, because it may cause extension of the
arms which are as yet unborn, and this creates a new and
difficult complication subsequently.
In most multiparous cases the legs are flexed, and a foot
may show outside the vulva during labour. There is a strong
temptation to pull on this foot, and this must be firmly
resisted until a vaginal examination has been done in order to
ascertain the degree of dilatation of the cervix, and to exclude
prolapse of the cord. If the cervix is found to be only two
to three fingers dilated, traction at this stage is futile. If the
cervix is almost fully dilated it may of course be possible to
pull down the leg and subsequently deliver the other leg
without much trouble.
Further traction almost certainly
causes extension of the arms, which will probably have to be
delivered by formal extraction under anaesthesia, but worst
of all the cervix may clamp around the foetal neck, and
delivery of the after-coming head degenerates into an
undignified struggle from which the victorious and sweating
obstetrician emerges rewarded by a vanquished baby-dead
or just alive. If the cervix is fully dilated, there is still little
to be gained by interference with what will almost certainly
be a straightforward natural delivery in response to uterine
action and expulsive effort. The golden rule in the management of the legs is to avoid traction where possible.

Delivery of the Arms


There are three methods of delivering the arms, the first of
which is simple delivery of the anterior arm as soon as the
shoulder appears beneath the pubic arch. Where the arms
have remained folded this presents no difficulty but where
it is not feasible Lovsett's manoeuvre should be employed.
This consists in a side-to-side lateral rotation of the foetal
trunk, combined with downward traction, in a twisting movement. Like the first method it can be done without undue
discomfort in the conscious patient who has had an episiotomy
done under local anaesthesia. It is generally successful in
bringing the anterior arm into view below the pubic arch,
from which position it can readily be delivered. The third
method is necessary where the arms remain extended, and
cannot be obtained even by the Lovsett manceuvre. General

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anaesthesia is necessary unless the baby is small, and the


technique is difficult. It should be emphasized that extended
arms are nearly always a consequence of unwise traction on
the legs by the medical attendant.

Delivery of the Head


The delivery of the after-coming head remains the climax
of the breech birth. The traditional Mauriceau-Smellie-Veit
method is widely used for this purpose, but it is potentially
risky for the foetus, in that traction which is applied through
the foetal neck may cause nerve root damage leading to upper
limb palsies such as the Erb-Duchenne or Klumpke types of
paralysis. Trauma of this sort is frequently the result of
applying traction in the wrong direction, or of swinging the
baby's body upwards too soon, before the head has reached
the pelvic floor. This difficulty is to some extent obviated in
Martin's method, in which the head is pushed through the
pelvis by pressure applied from above by the operator's
clenched left fist, while his right hand adopts the same
functions as in the former method. Direct pressure may be
applied to the head by a second person in the same way, but
there is the possibility of excessive force being used, with
consequent damage unless great care is exercised.
The best solution for the delivery of the after-coming head
is provided by application of Barnes's forceps. This however may prove difficult for the single-handed general practitioner, as an assistant is necessary to support the baby's
body while the blades are being applied.
This method

BRITISH

carries the advantage that traction is applied directly to the


greatest diameter of the foetal head precisely where it is
required. Virtually no traction is applied through the vulnerable neck, and thus foetal trauma is obviated to a great extent.
Pudendal nerve block is ideal for this type of delivery, and it
can be administered when the breech begins to distend the
perineum. The combination of this type of local anaesthesia
together with forceps application to the after-coming head
should be regarded as the safest method of delivery in most
cases of breech.

Conclusion
The recognition of abnormalities such as those described
above constitutes the most important initial step in their
eventual management. In this sphere the general practitioner
bears heavy responsibility towards his patient. The decision
as to the mode of delivery tends to be more in the sphere of
the specialist obstetrician. There is abundant opportunity
for improved levels of consultation between the two types of
medical practitioner on such occasions. There is no place at
all for mutual criticism, condemnation, or lack of communication in the conduct of an abnormal case, and no one stands
to suffer more in these circumstances than the patient and
her unborn baby.
REFERENCES

Rydberg, E., The Mechanism of Labour, 1954. C. C. Thomas, Springfield, Ill.


2 Vartan, C. K., 7. Obstet. Gynaec. Brit. Emp., 1949, 56, 650.
'
Feeney, J. K., 7. Irish med. Ass., 1953, 32, 46.
I

TO-DAY'S DRUGS

Treatment of Allergy
A panel discussion on this subject was held on 18 March. The members of the panel were Dr. R. S. BRUCE PEARSON
(Physician, King's College Hospital, London), Dr. F. RAY BETTLEY (Dermatologist, Middlesex Hospital), and Dr. JOHN
HUNT (General Practitioner, London). The chair was taken by a member of the B.M.7. editorial staff.

Definition
Chairman: I think we ought to begin with a short definition
of allergy. Dr. Pearson ?
Pearson: One might say that it now generally refers to
sensitivity reactions dependent on antigen/antibody mechanisms
that give rise to stereotyped groups of symptoms. But I
wouldn't claim this was a complete definition.

allergic. Yet the allergen here is in a sense a wavelength of


light.
Hunt: Someone once said that you can become allergic to
anything under the sun, including the sun itself.

Chairman: Dr. Bettley?


Bettley: The trouble is that sometimes there isn't an identifiable antibody. In, for example, eczema due to epidermal
sensitivity. There should be a defined antigen, of course.
Pearson: If the case remains true to type one can surely
assume that if an antigen exists there is also an antibody.
Hunt: What was von Pirquet's original definition?
Pearson: Von Pirquet in 1906 wrote that allergy was an
altered reaction consequent on an injection or on treatment by
some foreign substance, and included naturally occurring conditions such as hay-fever caused by grass pollen, urticaria caused
by substances such as strawberries or shell-fish, and reactions
to the stings of bees or other insects. Many of the simple
chemical substances which apparently act as antigens are complements which become attached to body protein, so that the
combined substance acts as an antigen.
Bettley: Then there is light sensitivity, for instance from
sunlight. This behaves in a way we would consider to be

Chairman: What are the common allergic conditions that


we ought to discuss ? Dr. Hunt?
Hunt: In general practice the commonest are hay-fever or
allergic rhinorrhoea, urticaria, asthma, eczema, sensitivity
dermatitis, and intestinal allergies, probably in that order of
frequency.
Chairman: What are the principles of treatment? Dr.
Pearson ?
Pearson: One must not be too tied down by the idea that
so-called allergic symptoms in a patient invariably have an
allergic cause, because identical symptoms are often caused by
other precipitating factors. It is important to take a very
careful history. If one finds an allergen then obviously the
first thing to do is to avoid it if this is possible. If it's not
possible, desensitization must be considered-if the symptoms
are sufficiently severe to justify it. On the other hand, if the
symptoms are mild one can often deal with them by
symptomatic treatment.

Principles of Treatment

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