Should my feets Up or Down?? PRESENTED BY:- AMIN HIMANSHU

HIMANSHU VASANTLAL
LA1-CO-163B(2)
CFU. DEPARTMENT OF OBS. & GYN.

1

TEACHER:- IRINA KAMILOVA

ON :- FETAL MALPRESENTATION

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.

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

Frank (Extended) Breech Presentation x Kneeling Breech Presentation
VERTEX
K Brow Presentation

K Face Presentation K Sincipital Presentation
TRANSVERSE

&

commonh

with

is completely extended.
• Incidence
• About 1:300 labours.

during pregnancy.
c. It is usually due to foetal causes

which may be:> Anencephaly: due to absence of the bony vault of the skull and the scalp while the facial portion is Normal
>Loops of the cord around the neck.
>Tumours of the foetal neck e.g. congenital goitre.
>Hypertonicity of the extensor muscles of the neck.
>Dolicocephaly: long antero-posterior diameter of the head, so as the breadth is less than 4/5 of the length.
>Dead or premature foetus.
> Idiopathic.

occurs during labour.
c. It may be due to:
>ontracted pelvis

particularly flat pelvis which allows descent of the bitemporal but not the biparietal diameter leads to extension of the head.
> Pendulous abdomen or marked lateral obliquity of the uterus.
>Further deflexion of brow or occipito - posterior positions.
>Other causes of malpresentations as polyhydramnios and placenta praevia.

mento-anterior (LMA).
d. Right mento-anterior (RMA), are the more common positions.
e.

Right mento-transverse (lateral), left mento-transverse, direct mento-posterior and direct mento-anterior are rare and usually transient positions.

position (LOA) as the back should be to the left

and anterior in the first position.Mento-anterior are more common than mento-posterior as most cases arise from more deflexion of the head in occipito-posterior position usually in flat contracted pelvis.

The limbs are felt more prominent in mento-anterior position.
*

The chin may be felt on the same side of the limbs as a
horseshoe-shaped rim in mento-anterior position.
* In mento-posterior, a groove may be felt between the occiput and the back particularly after rupture of the membranes.
* Second pelvic grip: the occiput is at a higher levelthan the sinciput.
* The FHS are heard below the umbilicus through the foetal chest wall in mento-anterior position.
* Ultrasound or X-ray: confirms the diagnosis and may identify associated foetal anomalies as anencephaly.

for face:
* supra-orbital ridges,
* the malar processes,
*

the nose (rubbery and saddle shaped),
* the mouth with hard areolar ridges.
* the chin.

it can be misdiagnosed as a buttock (breech presentation) where

the two cheeks are mistaken with buttocks and the mouth with anus and the malar processes with the ischial tuberosities.

form the apexes of a triangle.
The anus is on the

same line with the ischial tuberosities.

The gum is felt hard through the mouth. No hard object through the anus.

The examining finger may be sucked by the The anus does not suck the finger. foetal mouth during vaginal examination.

by submento-bregmatic diameter 9.5 cm.
• Increased extension.
• Internal

rotation of chin 1/8 circle anteriorly.
• Flexion: is the movement by which the head is delivered in mento-anterior position when the submental region hinges below the symphysis. The vulva is much distended by the submento-vertical diameter 11.5 cm.
• Restitution.
• External rotation.

pass the plane of pelvic inlet until the chin is

below the level of the ischial spines and the face begins to distend the perineum.
• Moulding does not occur as in vertex presentation.

so the head is delivered as mento-anterior.
b. In about

1/3 of cases one of the following may occur:
> Deep transverse arrest of the face: when the chinrotates 1/8 circle anteriorly.
>Persistent mento-posterior: when no rotation occurs.
• >Direct mento-posterior: When the chin rotates 1/8 circle posteriorly.
*In the last 3 conditions no further progress occurs and labour is obstructed.

because:
* Delivery should occur by extension while the head

isalready maximally extended.
* As the length of the sacrum is 10 cm and that of neck is only 5 cm, the shoulders enter the pelvis and becomeimpacted while the head still in the pelvis, thus the labour is obstructed.

occipito-posterior.
* Second stage:
> Spontaneous delivery usually occurs.
>

Forceps delivery may be indicated in prolonged 2nd stage.
>Episiotomy is necessary because of over distension of the vulva.

Second stage:Wait for long anterior rotation of the mentum

3/8 circle and the head will be delivered as mento-anterior.During this period oxytocin is used to compete inertia which is common in such conditions as long as there is no contraindication. Failure of this long rotation is more common than in occipito-posterior position so earlier interference is usually indicated.

circle or development of foetal or maternal distress at any

time, is managed by:
• Caesarean section: which is the safest and and the current alternative in modern obstetrics.
• Manual rotation and forceps extraction as mento-anterior, orthe current alternative in modern obstetrics.
• Craniotomy: if the foetus is dead.

in which the head is midway between flexion and extension.
•

Incidence
• About 1:1000 labour.

sinciput may be felt at the same level.
• Ultrasonography

and X-ray may be helpful.

reveals the following features:
> frontal bones,
> supra-orbital ridges,

and
>root of the nose but not the chin.

mento-vertical 13.5 cm which is longer than any diameter of

the inlet so there is no mechanism of labour and labour is obstructed.
* Transient brow:
may occur during conversion of vertex into face presentation. So if brow is flexed to become vertex or extended to become face it may be delivered.

if present do caesarean section.
> The case is considered

as transient brow, observed carefully and given a chance for spontaneous conversion into either face or vertex.
>The rest of management as other malpresentation.

present do caesarean section.
>The case is considered as transient brow,

observed carefully and given a chance for spontaneous conversion into either face or vertex.
> The rest of management as other malpresentation.

brow so:
> Caesarean section is done if the foetus

is living.
> Craniotomy if the foetus is dead.