FETAL

MALPRESENTATION
and
MALPOSITION
 Fetal Malpresentation

Fetal malpresentation refers to fetal

presenting part other than vertex and
includes breech, transverse, face,
brow, and sinciput.
Malpresentations may be identified
late in pregnancy or may not be
discovered until the initial assessment
during labor.
 Related Factors

• The woman has had more than

one pregnancy
• There is more than one fetus in
the uterus
• The uterus has too much or too
little amniotic fluid
• The uterus is not normal in
shape or has abnormal
growths, such as fibroids
• placenta previa
• The baby is preterm
 Types of
Malpresentation
BREECH
Complete (Flexed) Breech Presentation
Footling Breech Presentation
Frank (Extended) Breech Presentation
VERTEX
Brow Presentation
Face Presentation
Sincipital Presentation
TRANSVERSE

The diagnosis of abnormal fetal presentations is commonly made with

a combination of Leopold’s Maneuver, Vaginal examination, and
Ultrasound
 Types of
Malpresentation
BREECH
Breech presentation means that either the
buttocks or the feet are the first body parts that
will contact the cervix.

Breech presentations occurs in approximately

3% of the births and are affected by fetal attitude.

Breech presentations can be difficult births,

with the presenting point influencing the degree of
difficulty.
 Types of Breech
Presentation
Frank breech
The baby's bottom
Complete Breech
comes first, and the legs are The baby's hips and knees
flexed at the hip and
extended at the knees (with are flexed so that the baby is
feet near the ears). sitting crosslegged, with feet
65-70% of breech babies beside the bottom.
are in the frank breech
position.
 Types of Breech
Presentation
Footling Breech
One or both feet come
first, with the bottom at a
higher position. This is rare
at term but relatively
common with premature
fetuses.
 Maternal Risks
Prolonged labor r/t decreased pressure
exerted by the breech on the cervix.

PROM may expose client to infection.

Cesarean or forceps delivery.

Trauma to birth canal during delivery

from manipulation and forceps to free
the fetal head.

Intrapartum or postpartum hemorrhage.

 Fetal Risks:
Compression or prolapse of umbilical
cord.

Entrapment of fetal head in

incompletely dilated cervix.

Aspiration and asphyxia at birth.

Birth trauma from manipulation and

forceps to free the fetal head.
 Management
If the woman is in early labor and the
membranes are intact, attempt External
Cephalic Version.
Tocolytics, such as Terbutaline 0.25
mg IM, can be used before ECV to help
relax the uterus.
If ECV is successful, proceed with
normal childbirth. If ECV fails or is not
advisable, deliver by caesarean section.
 Management

Attempt external version if:

Breech presentation is present at or after 37
weeks (before 37 weeks, a successful version is
more likely spontaneously revert back to breech
presentation)
Vaginal delivery is possible
Membranes are intact and amniotic fluid is
adequate;
There are no complications (e.g. fetal growth
restriction, uterine bleeding, previous caesarean
delivery, fetal abnormalities, twin pregnancy, HPN,
fetal death).
 Management

VAGINAL BREECH DELIVERY is safe

and feasible under the following
conditions:
 - complete or frank breech
- adequate clinical pelvimetry
- fetus is not too large
- no previous caesarean section
for cephalopelvic disproportion
- flexed head.
 Management
CESAREAN SECTION is
recommended in cases of:
Double footling breech
Small or malformed pelvis
Very large fetus
Previous cesarean section for
cephalopelvic disproportion
Hyperextended or deflexed head.
 Types of
Malpresentation
TRANSVERSE
fetus lies horizontally
in the pelvis so that the
longest fetal axis is
perpendicular to that of the
mother.
The presenting part is
usually one of the
shoulders (acromion
process), an iliac crest, a
hand, or an elbow.
 Management

• External version – preterm and small

fetus
• Cesarean birth
 Types of
Malpresentation
SINCIPUT
the larger diameter of the
fetal head is presented.
Labor progress is slowed
with slower descent of the
fetal head.
FACE
The face presentation is caused
by hyper-extension of the fetal
head so that neither the occiput
nor the sinciput is palpable on
vaginal examination.  
Vertex Malpresentation
 Management
In the chin-anterior In the chin-posterior
position prolonged position, however, the
labor is common. fully extended head is
Descent and delivery of blocked by the sacrum.
the head by flexion may This prevents descent
occur. and labor is arrested.
 Management
Chin-Anterior Position
If the cervix is fully
dilated:
 Allow to proceed with
normal childbirth;
 If there is slow progress
and no sign of
obstruction, augment
labor with oxytocin;
 If descent is
unsatisfactory, deliver by
forceps.
If the cervix is not fully
dilated and there are no
signs of obstruction:
 augment labor with
oxytocin.
Chin-Posterior Position
If the cervix is fully
dilated:
 Deliver by caesarean
section.
If the cervix is not fully
dilated
 Monitor descent, rotation
and progress. If there are
signs of obstruction,
deliver by caesarean
section.
*Do not perform vacuum
extraction for face
presentation.
 Types of
Malpresentation

BROW
The brow
presentation is
caused by partial
extension of the
fetal head so that
the occiput is MGT:
MGT If the fetus is alive or dead,
higher than the deliver by caesarean section.
sinciput.
*Do not deliver brow presentation
by vacuum extraction, outlet
forceps or symphysiotomy.
 RISKS OF BROW
PRESENTATION
• Longer labor caused by ineffective
contractions and slow or arrested fetal
descent.
• Dysfunctional labor patterns
• Cesarean birth if brow presentation persists
or if the fetus is large
• Fetal/neonatal risks: mortality because of
cerebral and neck compression and damage
to the trachea and larynx
Nursing Care of Clients with
Malpresentations
• Observe closely for abnormal labor patterns.
• Monitor fetal heart beat and contractions
continuously.
• Anticipate forceps-assisted birth.
• Anticipate cesarean birth for incomplete breech or
shoulder presentation.
• Be prepared for childbirth emergencies such as
cesarean section, forceps-assisted delivery, and
neonatal-resuscitation.
• Position pt. in Trendelenburg or knee-chest position.
• Manually raise the presenting part aseptically
Anxiety
Provide client and family teaching,
Be available to client for listening and talking
Provide client support and encouragement.
Encourage client to acknowledge and express feelings.
Encourage breathing exercises to relieve anxiety.
Fear
Provide client and family teaching,
Note for degree of incapacitation.
Stay with the client or make arrangements to have
someone else be there.
Provide opportunity for questions and answer honestly.
Explain procedures within level of client’s ability to
understand and handle.
Risk for Injury
Observe closely for abnormal labor patterns.
Monitor fetal heart beat and contractions continuously
Be prepared for childbirth emergencies such as cesarean
section, forceps-assisted delivery, and neonatal-resuscitation.
Maintain sterility of equipments
Anticipate forceps-assisted birth.
Anticipate cesarean birth for incomplete breech or shoulder
presentation.
Risk for infection
Stress proper hand washing techniques of all caregivers.
Maintain sterile technique.
Cleanse incision site daily and prn.
Change dressings as needed.
Encourage early ambulation, deep breathing, coughing,
and position change.
 Fetal Malposition

Refers to positions other than an

occipitoanterior position.
position
Malpositions include
occipitoposterior and
occipitotransverse positions of fetal
head in relation to maternal pelvis.
It is usually seen in multipara or
those with lax abdominal wall. Fetal
malpositions are assessed during
labor.
 Left Occipitoanterior
Rotation

• (A) A fetus in cephalic presentation, LOA position. View is

from outlet. The fetus rotates 90 degrees from this position.
(B) Descent and flexion (C) Internal rotation complete. (D)
Extension; the face and chin are born
 Types of Fetal Malposition
Occipitoposterior Position
Arrested labor may occur
when the head does not
rotate and/or descend.
Delivery may be complicated
by perineal tears or extension
of an episiotomy.
Occipitotransverse Position  
It is the incomplete
rotation of OP to OA results in
the fetal head being in a
horizontal or transverse
position (OT).
Left Occipitoposterior
Rotation
• (A) Fetus in cephalic
presentation LOP
position. View is from
outlet. The fetus
rotates 135 degrees
from this position. (B)
Descent and flewion.
(C) In ternal rotation
beginning. Because
of the posterior
position, the head
will rotate in a longer
arc than if it were in
an anterior position.
(D) Internal rotation
complete. (E)
Extension; the face
and the chin are born.
(F) External rotation;
the fetus rotates to
place the shoulder in
an anteroposterior
position
 Maternal risks: Maternal symptoms:
• prolonged labor • Intense back pain in
• potential for operative labor
delivery • Dysfunctional labor
• extension of pattern
episiotomy, • prolonged active phase
• 3rd or 4th degree • secondary arrest of
laceration of the dilatation
perineum. • arrest of descent

Diagnosis:
Abdominal examination – the lower part of the abdomen is
flattened, fetal limbs are palpable anteriorly and the fetal flank.
Vaginal examination – the posterior fontanelle is toward the
sacrum and the anterior fontanelle may be easily felt if the head
is deflexed
Ultrasound
 Nursing MGT
Encourage the mother to lie on her side from the fetal back,
which may help with rotation.
Pelvic – rocking may Knee – chest position
help with rotation. may facilitate rotation.

Apply sacral counter – pressure with heel of hand to relieve

back pain.
Continue support and encouragement:
Keep client and family informed progress.
Praise client’s efforts to maintain control.
 Management
• If there are signs of obstruction or the fetal
heart rate is abnormal at any stage,
stage deliver by
caesarean section.
• If the membranes are intact,
intact rupture the
membranes with an amniotic hook or a
Kocher clamp.
• If the cervix is not fully dilated and there are
no signs of obstruction,
obstruction augment labor with
oxytocin.
• If the cervix is fully dilated but there is no
descent in the expulsive phase,
phase assess for
signs of obstruction.
 Management

If the cervix is fully

dilated and if:

• the leading bony edge of

the head is above -2
station, perform caesarean
section;
• the leading bony edge of • If the operator is not
the head is between 0 proficient in
symphysiotomy, perform
station and -2 station, caesarean section;
Delivery by Vacuum
Extraction and • If the bony edge of the fetal
Symphysiotomy head is at 0 station, deliver
by vacuum extraction or
forceps.
 Management
SYMPHYSIOTOMY
A surgical procedure in
which the cartilage of the
symphysis pubis is divided to
widen the pelvis allowing
childbirth when there is a
mechanical problem.
Currently the procedure
is rarely performed in
developed countries, but is
still routine in developing
countries where cesarean
section is not always an
option.
 Management
Forceps - provides traction or
a means of rotating the fetal
head.
Risks: fetal ecchymosis or
edema of the face, transient
facial paralysis, maternal
lacerations, or episiotomy
extensions.
Vacuum extraction - Provides
traction to shorten the second
stage of labor.
Risks: newborn
cephalhematoma, retinal
hemorrhage and intracranial
hemorrhage.
 Nursing Diagnoses:
Impaired gas exchange
Encourage the mother to lie on her side from the fetal back, which may
help with rotation.
Knee – chest position may facilitate rotation.
Pelvic – rocking may help with rotation.
Monitor FHB appropriately
Be prepared for childbirth emergencies such as cesarean section,
forceps-assisted delivery, and neonatal-resuscitation.
Pain
Encourage relaxation with contractions.
Apply sacral counter – pressure with heel of hand to relieve back pain.
Provide comfortable environment.
Teach breathing exercises for use during early labor until client receives
pharmacologic relief.
Monitor physical response for example, palpitations/rapid pulse
 Nursing Diagnoses:

Fatigue
Assess psychological and physical factors that may affect reports of
fatigue level
Monitor physical response for example, palpitations/rapid pulse
Monitor fetal heart beat and contractions continuously.
Refraining from intervening with client during contraction.
Anxiety
Keep client and family informed progress.
Provide support during labor through personal touch and contact.
These methods convey concern.
Continue support and encouragement.
Make the client feel she is somewhat in control of her situation.
Provide client and family teaching.
Identify client’s perception of the threat presented by the situation.
 FETAL DISTRESS
CAUSES:
•Compression of the umbilical cord
•Uteroplacental insufficiency caused by
placental abnormalities or maternal
condition (prolonged labor, HPN,
DM,infections
•Prolonged labor-CPD, breech
presentation, failure of the cervix to dilate
SIGNS AND SYMPTOMS
• Meconium-stained amniotic fluid
• Changes in fetal heart rate baseline:
- tachycardia
- bradycardia
• Decreased or absence of variability of
heart rate
• Late deceleration pattern
• Severe variable deceleration pattern
 NURSING CARE
• ASSESSMENT AND NURSING
DIAGNOSES
1.Assess FHR baseline, variability and
pattern of periodic changes
2.Assess contraction pattern and maternal
response to labor
3.Dx: Decreased cardiac output (fetal),
Impaired gas exchange, Anxiety
Planning and Implementation
• Late deceleration:
1.Reposition mother on her left side
2.Administer O2 by face-mask at 8-10 lpm
3.Increase IV fluids
4.Discontinue oxytocin infusion, if labor is
being induced
5.Notify the physician immediately
• Severe variable decelerations or
prolonged bradycardia
1.Reposition the mother on either side
2.If not corrected, reposition to opposite side
3.Administer O2 by face-mask at 8-10 L/min
4.Trendelenburg or knee-chest position, if
not corrected
5.Apply upward digital pressure on the
presenting part to relieve pressure on the
umbilical cord
• Provide appropriate information and
emotional support
• Maintain continuous monitoring of FHR and
uterine activity, and labor progress.
• Evaluation
1. The fetal heart rate remains in normal
range with adequate variability and
absence of ominous periodic changes
2. The client verbalizes that anxiety is
decreased
3. Family coping strategies are strengthened
 MEDICAL MANAGEMENT
• Amnioinfusion
• Intrauterine resuscitation
• Prevention of meconium aspiration
 Prolapsed Umbilical Cord
• Cause: fetus is not firmly engaged
• Contributing factors:
1.ROM before engagement
2.Small fetus
3.Breech presentation
4.Multifetal pregnancy
5.Transverse lie
6.Polyhydramnios
7. Long cord
8. Spontaneous or artificial rupture of
membranes before presenting part is
engaged
 ASSESSMENT
• Identify the client at risk for prolapsed
umbilical cord
• Assess for the following:
- Fetal hypoxia
- irregular FHR
- Umbilical cord can be felt on cervix/vagina
- Variable deceleration
- Cord may be protruding from the vagina
- Fetal distress
- Fetal bradycardia
 NURSING DIAGNOSES
• Risk for impaired gas exchange
• Risk for injury
• fear
 Nursing Management
• NOTE: The nurse’s #1 priority action is
to assess the Fetal Heart Rate
• Primary goal :
 to remove the pressure from the cord
 PLANNING AND
IMPLEMENTATION
• Place mother on knee-chest or t-burg
position
• Push fetal presenting part upward
Note!
• Do not push cord back to uterus
• Administer O2 by face mask at 8-10 lpm
• Maintain continuous electronic fetal
monitoring
• Prepare for rapid delivery vaginally or
by CS
• If cord protrudes through the vagina,
apply sterile saline soaked dressing to
prevent drying
 Complications:

• Maternal & Fetal Infection

 Compression of the cord and
compromising fetal circulation
 EVALUATION
• The fetal heart rate remains within normal
range and without ominous signs
• The fetus is safely delivered
• The client and family verbalized
understanding of the implications of
prolapsed umbilical cord and the need for
emergency management
 QUIZ TIME!!!!!!!!!!!!
1. All but one are causes of fetal
distress?
a. Placenta previa
b. Congenital defects
c. CPD
d. None of the above
Which of the following indicates fetal
distress?
a.Meconium staining
b.FHR- 100bpm
c.Greenish amniotic fluid
d.All except C
e.All of the above
3. Which of the following interventions
should the nurse perform first when
fetal distress is noted?
A.Position client to left side-lying
B.Give oxygen
C.Maintain IVF
D.Report to MD
• 4-5. Give 2 s/s of fetal distress