ABNORMALITIES IN FETAL POSITION

BREECH PRESENTATION
− 3-4% of all deliveries
− most common type of malpresentation comprising 75% percent of our mal-
− presented fetus.

PREDISPOSING FACTORS

-prematurity
-uterine malformation or fibroids
-polyhydramnios
-very short umbilicus
-placenta previa
-fetal abnormalities(eg. Hydrocephalus, anencephaly,neck masses
-multiple gestation

DIAGNOSIS
-occurs when the buttocks and /or feet are the presenting parts.
− -on palpation (leopolds maneuver) the head is felt in the upper abdomen
− and the breech in the pelvic brimle
− -auscultation locates the fetal heart higher than expected with a vertex
− presentation
− - on vaginal examination during labor, the buttocks/feet are felt, thick dark
dark meconium is normal.

TYPES OF BREECH PRESENTATION

1 Frank (extended ) Breech

2 -occurs when both legs are flexed at the hips and extended at the knees.
3 Complete (flexed ) Breech
4 -occurs when both legs are flexed at the hips and knees.
5 Footling breech
6 -occurs when a leg is extended at the hip and the knee.

MECHANISM OF LABOR

In breech presentation, the baby's bottom (rather than the feet and knees)
is commonly the first to descend through the maternal pelvis and emerge from the
vagina.
COMPLICATIONS

− head entrapment
− birth trauma (broken neck, brachial plexus injury)
− cord prolapse
− birth asphyxia (neurologic damage)
−
 TRANSVERSE LIE AND SHOULDER PRESENTATION

-Occur when the long axis of the fetus is perpendicular to that of the mother such that the
shoulder is over the pelvic inlet and becomes the presenting part, the head in one iliac fossa and the
breech in the other.
-when the fetal long axis forms an acute angle with the maternal long axis an oblique lie
results( unstable lie).

COMMON CAUSES

-multiparity
-pendulous abdomen
-preterm gestation
-placenta previa
-uterine anomaly
-polyhydramnios
-contracted pelvis

DIAGNOSIS
-can be suspected by inspection alone-the abdomen is unusually wide and the fundus is
only slightly above the umbilicus.
− on leopolds maneuver neither the head nor the the buttocks can be felt in the fundus, the head is
in one iliac fossa and the breech in the other, when the fetal back is anterior, a smooth hard resistance
plane is felt across the front of the abdomen and when it is posterior, small nodular parts are felt.
− on vaginal examination, the thorax can be recognized by the “gridiron” feel of the ribs, the
scapula and clavicle can be felt opposite the thorax, the shoulder may be felt but not always. In advance
labor the shoulder becomes wedged in the pelvic cavity and the hand or arm may prolapse so that the
elbow, arm or hand may be felt in the vagina.

MECHANISM OF LABOR
-cannot be delivered vaginally and would require cesarean delivery-

COMPLICATIONS
-prolapsed umbilical cord
− -rupture of the uterus

Management -
-if in active labor-cesarean section
-if not in labor-external cephalic version(ECV) can be attemted provided
− there are no contraindications to the procedure.
− -monitor signs of cord prolapse.
 BROW PRESENTATION
-rarest type of malpresentation
− it is caused by partial extention of the fetal head so that the occiput is higher than the sinciput in
contrast to a well flexed head(vertex presentation) wherein the occiput is lower than the sinciput.
− The fetal head assumes a position midway between full flexion (occiput) and full extension
(mentum or face ).
− the presenting diameter is occipitomental.

DIAGNOSIS

-on abdominal examination, more than half of the fetal head is above the symphysis pubis
and occiput is palpable at a higher level than the sinciput.
− -on vaginal examination, the ant fontanel, frontal sutures, orbits and nasal bridge are felt.
MECHANISM OF LABOR
-Brow presentation is unstable and often converts spontaneosly to occiput or face
presentation.
-if brow persist, dystocia occurs
-if the fetus is small and pelvis is large, labor will be easy, if large fetus engagement is not
possible since the presenting occipitomental diameter is disproportionately big for the pelvis unless
marked molding occurs.

MANAGEMENT

-deliver by cesarean section

− if the fetus is dead -cervix not fully dilated- cesarean section if fully dilated
− and fetus is macerated deliver vaginally, if no complication occurs.

FACE PRESENTATION

− -is caused by hyperextension of the fetal head so that so that the occiput is contact with the fetal
back and the chin(mentum) is presenting.
−
ETIOLOGIC FACTORS

-contracted pelvis
− -pendulous abdomen
− - large fetus
− -anencephalic fetus
− -neck enlargement
− -cord coils

DIAGNOSIS

-on abdominal examination-a groove may be felt between the occiput and the back and the
cephalic prominence is palpated at the same side as the fetal back.
-on vaginal examination neither the occiput nor the sinciput is palpable, but rather
distinctive features of the face: the mouth and two malar prominences are palpated.

MECHANISM OF LABOR

-it is necessary to distinguish chin (mentum) anterior position from chin posterior position-
because on the latter position the fetus cannot be deliver vaginally, unless rotation to mentum anterior
occurs.
-mentum anterior-descent and delivery of the head are accomplished by flex ion. The
cardinal movements of labor are in the following order: engagrment, descent,fexion, and external
rotation.
-mentum posterior-flexion of the head is impeded by compression of the fetal brow against
the symphysis pubis.

MANAGEMENT

-for anterior position -if the cervix is fully dilated

-allow labor to proceed to normal childbirth
-if there is slow progress and there are no signs of obstruction, augment labor with oxytocin.

For chin posterior position

− if the cervix is fully dilated, deliver by cesarian section.

− Not fully dilate monitor, however if there is obbstruction -CS
− if fetus is dead -CS

COMPOUND PRESENTATION

-presence of an extremity alongside the presenting part

− -dx is enternal examination only
-management -the prolapsed part should be left alone , most often it will not interfere with
labor or will retract spontaneosly,
-if there is cord prolapse, deliver by CS.

ABNORMALITIES IN FETAL POSITION

-persistent occiput posterior position

-most common abnormal fetal position causing dystocia. When
the fetus is in occiput posterior wherein the fetal neck is somewhat deflected and a larger
occipitofrontal diameter rather than the suboccipitobregmatic diameter of the fetal head must pass thru
the pelvis.

-FACTORS ASSOCIATED WITH OCCIPUT POSTERIOR

-nulliparity
-maternal age>35.
 -AOG >41 weeks
-birth weight 4,000g,
-artificial membrane rupture
-epidural anesthesia

DIAGNOSIS
-occurs when the fetal occiput is posterior in relation to maternal pelvis. On
abdominal examination, the lower part of the abdomen is flattened , fetal limbs are palpable anteriorly
and fetal heart may be heard at the flank area.
-diagnosis is by digital vaginal examination which can determine the orientation of
fetal sutures and fontanels . On vaginal examination , the posterior fontanel is towards the sacrum and
the anterior fontanel may be easily felt if the head is flexed.

Mechanism of labor
-normal in early labor
-result of malrotation of occiput anterior position to occiput posterior position during
labor .
− in occiput posterior -the head engages in a military attitude with the occipitofrontal diameter as
the initial presenting diameter . In 87 percent of cases, the head undergoes internal rotation to occiput
anterior position followed by flexion as it reaches the pelvic floor changing the presenting diameter to a
shorter diameter which is suboccipitobregmatic followed by uncomplicated delivery. However if it does
not rotate , the fetal head pressed against the symphysis pubis is prevented from undergoing flexion
upon descent , thus the larger occipitofrontal diameter remains as the presenting diameter. The head
finally delivers by flexion with the fetal faced up.
− Posterior presentations are normal.

PERSISTENT OCCIPUT POSTERIOR (POP)

-result when there is failure of rotation which happen when the mid pelvis is
contracted.
-most common malposition at delivery, more common in nulliparas.

− both the first stage and second stage of labor are prolonged
− the likely hood of operative and instrumental delivery are greater.

COMPLICATIONS
− increased incidence of prolonged pregnancy
− premature rupture of membrane
− oxytocin induction and augmentation
− chorioamnionitis

-severe perineal and vaginal lacerations

− excessive blood loss
− postpartum infection
− associated with higher risk of adverse neonatal outcomes compared with
− neonates delivered in the anterior occiput position.
 MANAGEMENT
-if there are signs of obstruction or fetal heart rate is abnormal-deliver
by cesarean section.
-if the membrane are intact, rupture the memb.
− if the cervix is not fully dilated but there are no signs of obstruction
− augment labor with oxytocin.
− If cervix is fully dilated but there is no descent in the expulsive phase, assess for signs of
obstruction , if no signs of obstruction, augment labor
− with oxytocin.
− If the cervix is fully dilated and the fetal head is at station -2, perform CS.
− If the head is at station 0,deliver by vacuum extraction or forceps.
− Manual rotation

PERSISTENT OCCIPUT TRANSVERSE

-occurs when the fetal occiput is in the right or left of the

maternal pelvis with the sagittal suture along the transverse diameter of the
maternal pelvis.
-transitory position, if pelvis is normal it will rotate to anterior
position.
-however if the pelvis is of the platypelloid type, transverse position may persist and
with further descent the head may end up in a
deep transverse arrest that would need CS delivery.

ASYNCLITISM
-is the lateral deflexion of the fetal head in labor so that the sagittal suture is not in
the midline of the birth canal, deflected anteriorly toward the symphysis
pubis( posterior asynclitism or posteriorly toward the sacrum (anterior asynclitism).

ABNORMALITIES OF FETAL SIZE

MACROSOMIA-defined as fetal weight of 4500g or more

-most common etiology
-posterm pregnancy
-gestational diabetes
-maternal obesity
-multiparity
-fetal weight determination by
-leopolds maneuver
-ultrasound
 -the primary concern in macrosomic fetus is the risk of shoulder dystocia-so that
clinicians often times opt to proceed with cesarean delivery.

ABNORMALITIES IN FETAL SHAPE

-fetal anomalies can cause dystocia
-hydrocephalus\
-encephalocoele
-enlarged abdomen
-neck and rump tumors
-acardiac co- twin

SHOULDER DYSTOCIA-refers to the entrapment of the fetus within the birth canal
resulting from infaction of either anterior shoulder(most common) against maternal pubic bone or the
posterior shoulder (least common)against the bony protuberance of the sacral bone (sacral promontory).

PRECONCEPTUAL RISK FACTORS

-previous shoulder delivery

-maternal obesity
-maternal age
-multiparity
-abnormal pelvis

ANTEPARTUM RISK FACTORS

-macrosomia
-diabetes
-excessive weight gain
-post-dates/posterm

INTRAPARTUM RISK FACTORS

-instrumental delivery
-prolonged second stage
-multiple risk factors

The first sign of shoulder dystocia occurring is the “turtle sign” wherein the fetal
head after emerging recoils tightly against the maternal pereneum.

Dystocia of anterior shoulder-when the sholder fail to adequately rotate from upon
reaching the pelvic inlet, the anterior fetal shoulder may become impacted on the maternal pubic bone.
The shoulder may spontaneously dislodge, and may go unnoticed however if the impaction persist, fetal
injury may occur.
Dystocia of the posterior shoulder-may also result from inadequate rotaton of the fetal
shoulders as they enter the pelvic inlet-in this case the posterior shoulder impacts against the
promontory of the sacrum.

FETAL INJURIES RELATED TO SHOULDER DYSTOCIA

-brachial plexus injury
-bone fracture in the affected side
-perinatal asphyxia, brain damage and death

MATERNAL INJURIES RELATED TO SHOULDER DYSTOCIA

-post partum hemorrhage
-extension of episiotomy and fourth degree lacerations
-cervical and vaginal lacerations
-loss of bladder function
-uterine rupture
-separation of the maternal pubic symphysis pubis
-femoral cutaneous nerve injury related to overzealous use of
-Mc-Roberts maneuver
-puerperal infection

Reduction maneuvers for shoulder dystocia (the HELPERR Mnemonic)

4P's that should be avoided

-pull
-push
-panic
-pivot

These maneuvers are designed to do one of three things

-inc. functional size of the bony pelvis(Mc-Roberts)
-dec. the bisacromial diameter of the fetus (suprapubic pressure)
-change the relationship of the bisacromial diameter within the bony
pelvis (woods screw)

HELPERR Mnemonic ACTION PLAN for shoulder dystocia

H-call for help

E-evaluate for episiotomy
L-legs flexed and abducted (Mc-Roberts maneuver)
P-suprapubic pressure
E-enter maneuvers (wood'screw and Rubin maneuver)
R-remove the posterior arm
R-roll the patient
ALARMER mnemonic has same maneuvers as the HELPERR mnemonic

A-ask for help

L-lift/hyperflex legs
A-anterior shoulder disimpaction
R-rotation of the posterior shoulder
M-manual removal of the posterior arm
E-episiotomy
R-roll over onto “all fours”

Call for help

Evaluate for Episiotomy

Legs (mc roberts maneuver)
Suprapubic pressure (mazzanti maneuver)
Enter maneuvers (internal rotation )
-include the following
-Rubin-II
-Woods corkscrew
-Reverse Woods corkscrew
Remove the posterior arm
Roll the patient
Maneuver of last resort
-deliberate Clavicle Fracture
-Zavanelle maneuver
-abdominal surgery with hysterotomy
-symphysiotomy