Malpositions and Malpresentations in Midwifery (PDF)

# Malpositions and Malpresentations **A malpresentation of the fetus is any presentation other than the vertex. OR A condition in which a baby is not in the usual head-first position for childbirth.** ## Such presentations/position often presents the midwife with a challenge with both the recognit...

# Malpositions and Malpresentations **A malpresentation of the fetus is any presentation other than the vertex. OR A condition in which a baby is not in the usual head-first position for childbirth.** ## Such presentations/position often presents the midwife with a challenge with both the recognition and diagnosis in pregnancy and labour. Failure to do so could lead to serious complications such as obstructed labour, uterine rupture, as well as fetal and maternal death. ## The presentations /positions include, Breech, face, brow, unstable lie, occipito-posterior positions, and compound presentation, transverse, oblique # Breech Presentation ## Definition - This occurs when buttocks of the fetus lies on the lower pole of the interne OR on the lower pole of the uterus with its buttocks. ## Most babies present by cephalic but there are few that present as breech and the incidence is 1:40 at term or 3-4%. But the incidence is higher during the midterm (28th-30th wk) which is 25% in incidence ## The reasons are as follows: 1. The baby is relatively small and very mobile 2. The quantity of liquor amnie is great in relation to the size of the baby. ## After the 34th wk of pregnency, the baby starts adding considerable weight to the liquor amnic decreases and the boosy maintains a definite position. ## Pre disposing Factors (Maternal) 1. Type of pelvis - contracted pelvis favours malpresentation and in this case the Android pelvis is an example. A transverse bisection of the brim saves more room posteriorly than anteriorly. 2. Quantity of Liquor amni - Polyhydraminous 3. Situation of the placenta - Low lying placenta, Maternal ## Causes of Breech (Maternal) 1. Malformation of the uterus (a septum in the uterus which prevents spontaneous rotation of the fetus). (Bicornuate uterus) 2. Multiparity, ## Fetal Causes /Factors 1. Prematurity 2. fetal abnormality (Hydrocephaly, Anaencephaly) 3. Polyhydraminous 4. 1.UFD- There is hypotonicity (loss of muscletone 5. Multiple pregnancy # Types of Breech Presentation ## There are basically two types of breech: - The complete breech - The incomplete breech ## Complete Breech - The attitude is that of complete flexion (Back is bent) ## The Incomplete Breech - Here we have 3 types: - Complete, frank, footling, knee position 1. **Frank Breech** - In this, the legs are extended. 2. **Footling Breech** - One of the legs has prolapsed. 3. **Knee Presentation** - Here, one of the knees tends to be prolapsing. # Positions in Breech ## There are 6 major positions in breech: * Here, the sacrum is the denominator. 1. LSA - Left Sacro Anterior 2. RSA - Right Sacro Anterior 3. LSL - Left Sacro Lateral 4. RSL - Right Sacro Lateral 5. LSP - Left Sacro Posterior 6. RSP - Right Sacro Posterior # Diagnosis ## History Taking - The woman will repeatedly complain of discomfort at the upper part of the abdomen (under her ribs especially at right). ## Abdominal Examination - * On inspection, nothing is revealing * On palpation - a ballotable hard mass is felt on the fundus while the lower part of the uterus contains a soft mass. If breech is anterior, ask client turn to her side, (Left Lateral position), the head can be palpated especially in obese women and in polyhydraminous. ## FH - fetal heart. ## E.C.U - External cephalic version * Auscultation - FHt is heard above the umblicus. If engagement has taken place, the FHt is heard at the level of the umblicus. * Per Vaging - feels soft smooth. mass, no definite Landmark. For complete breech, the feet of the baby may be felt. The external genitalia may be felt and sometimes the Ischial tuberosity. If the membrane has ruptured and the cervix is fully dilated, the examining finger could be inserted into the fetal anus with meconium staining the finger. ## Abdominal X-ray - Confirms not only the diagnosis but assesses the type of pelvis, type of breech, the size of the beasy, presence of fetal abnormality and whether the head can pass thus the brim or not. ## An X-ray is essential for a primip that present with breech presentation. ## Ultrasonography could be done. # Management During Pregnancy ## Usual ante-natal mat until the 34th wk, then refer her to the doctor (Obstetrician). ## There are varying schools of thought: 1. Leave the pregnancy and there will be spontaneous rotation 2. An ECU could be done (though is now). 3. For a primip with breech, C.S. is done. # Breech # External Cephalic Version ## This is an attempt to manipulate the fetus from a breech presentation to cephalic by manual manipulation on the mother's abdominal wall. ## Optimal Time for E.C.V - 36th wk for a multigravida because she has laxed abdominal and uterine wall and because then baby is reasonably big to remain in the cephalic position since the abdomen is roomy. - 34th wk for a primigravida because she has firm abdominal muscle which will serve as a binder for the beasy to remain in this position. ## How is E.C.V Done (Procedure) ## An appointment is given for 2wks - 32nd wk for priming and 34th wk for multip. ## Midwife's Responsibility 1. Explain procedure to client and obtain consent simply and plainly. 2. Ensure that bladder and rectum are empty. 3. Set up tray containing: * Pair of gloves * Talcum powder * Fetal stethoscope * Sterile perineal pads * Things for vulva swabbing * Receiver for used swabs ## Place patient on dorsal position. Check fetal heart beat/rate. Get/summon the doctor. Auscultates. * Palpates to confirm breech presentation * Identify the fetal back * Sprinkle fine powder on the pt. abdomen, and rub smoothly. * Find baby's back and gently rotate it following the body’s face. * The head is pushed into the brim. * Do another auscultation followed by V.F to confirm a cephalic presentation. * The midwife checks the FHt beat because this causes fetal tachycardia - It is done every 5 mins for 8 mins, every 15 min. for 30 mins. and every 30 mins for 4 hours. * Accurate monitoring of the client's pulse rate and BP. * Client is admitted in the ante-natal ward and discharged 5-6 hours later. If everything is normal or the next day. * If client is bleeding or draining liquour estimate the quantity drained by keeping the used perineal pad. # Complications Of E.C.V 1. Premature seperation of the placenta (Placenta praevia) 2. Alteration in the fetal heart beat and rate. 3. Tightening of cord round the neck of the fetus, which causes strangulation. 4. Tightening of true knot which may not be tightened until E.C.V and there will be sudden cessation of fetal heart beat. 5. Premature rupture of membrane 6. Premature Labour. # Contraindictions For E.C.V 1. Elderly primip 2. Previous C.S scar 3. In multiple pregnancy. 4. Hydrocephaly 5. Placenta previa 6. High blood pressure 7. Polyhydraminous # Management In Labour ## Delivery must be conducted in a well equipped hospital (why) * Frequent observation and monitoring in labour is required. * Midwife must be with pt and avoid unnecessary interference. * She should explain to the client to avoid premature bearing down. * Sedate pt as necessary. * Elevate the foot of the bed to alleviate the pressure on the cervical nerve endings that stimulates the woman to bear down prematurely. * Determine the type of breech * Determine the level of cervical dilatation. * Determine the type of analgesic to be given (how) * To know the station of the breech. * To know the progress of labour. # Diet: * Mottling is given orally. * Maintain intake and output chart. # Once labour has been established, notify the doctor ## Summary - Need for prompt action * Avoid unnecessary interference * Intelligent observation * Avoid injury both to mother and baby * Get things for episiotomy ready -10ml syringe, Episiotomy scissors, Local anaesthetic agent. * Things for pudendal nerve block. * Oxygen apparatus * Suction apparatus. * Drugs for resuscitation- Hydrocort, Vit K, Sodium Bicarbonate, konacion. * Certain other personnel shld be present - obstetrician, paediatrician, anaesthetist. * Provide a warm cot (Hot H2O bottles used) # Delivery of Breech ## There are two types of breech delivery effort 1. Breech extraction - Done by the Br. under C.A. 2. Assisted Breech Delivery - Done by maternal, the midwife assists in one way or the other. # Delivery Proper - ## When the breech is distending the perineum, the anus tends to gape. * The assistant positions the pt in either Lithotomy or dorsal position with the buttocks at the edge of the bed/couch. * Encourage her to bear down with contraction and to rest when contraction stops. * Check fetal heart beat after each contraction. # Delivery Of The Buttock's And Trunk 1. Swab the vulva 2. Observe the stretching of the perineum. If perineum is stretching well, fire but if not infiltrate with local anaesthesia and give her episiotomy as the buttocks decends and the baby’s legs by spliating the legs and bringing them down one after the other. 3. Then allow for restitution and encourage to continue bearing down until you reach the level of the umblicus, and pull a loop of cord. 4. Do a V.F to ascertain whether the upper arms are flexed at the chest. 5. If the shoulders are taking time to descend, apply a downward traction and the thumbs shld rest on the baby’s sacrum and rest the rest of the illiac crest. 6. If your fingers are placed higher, the abdominal visceral organs may be damaged. 7. If the hands are extended, do a Louset manouure turning the baby 180 degree then splint the anterior hand and deliver. 8. Turn again in the same direction (clock-wise) and the other hand is splinted and delivered. 9. Allow the head to hang until you see the hair line, then apply a down traction with contractions encouraging mother to bear down until the head is delivered by lifting the baby up over the mother’s abdomen. # Mechanism Of Labour In Breech * Lie - Longitudinal * Altitude - Complete flexion * Presentation - Breech * Denominator - Sacrum * Position - LSA - Left Sacro Anterior position * Presenting Part - Anterior buttock ## At the onset of labour, the sacnim points to the left ilio-pectineal eminence with bitrochanternic diameter of 10cm engaging. ## Movement - Detent occurs with increasing contraction. * The anterior buttocks reaches the pelvic floor and rotates 1/8 of circle to the front bringing the bitrochanteric diameter of into the anterior - posterior diameter of the out let. * The anterior buttocks gets caught behind the symphysis pubis and by lateral flexion the body the posterior buttock sweeps the perineum and the breech and the legs are born. * The shoulders enter the brim in the left oblique diameter. * The anterior shoulder reaches the pelvic floor first and is rotated 180 of a circle to the front bringing the shoulders into the anterior-posterior diameter of the outlet. * The anterior shoulder slips under the symphysis pubis. The posterior shoulder sweeps the perineum and the shoulders are delivered. * The head enters the brim and the traverse diameter. ## Because of the weight of the body, the head is usually partially deflexed so that the sub occipito frontal diameter engages. * The occiput reaches the pelvic floor and is rotated to the front becoming caught behind the symphysis pubis. * Simultaneosly there is external rotation of the body so that the back lies upper most? * The chin, face and sincipit sweeps the perineum and the head is delivered by flexion. ## **Burns Marshal Method** * Once the occiput has rotated and the hair line is visible, the midwife faces away from the pt’s head and with her left hand grasps the baby’s feet. Exerting steady traction she pulls first downwards, then keeping the body on the stretch outwards and finally upwards so that the sub-occipital region pivots under the symphysis dubis. * With the right hand guide the perineum. Once the mouth and nose are free, clear the upper airways so that the baby can be delivered as slowly as possible to permit moulding. * __EXTENDED HEAD = FRANK BREECH.__ * If the pt is unable to deliver the buttocks spontaneously due to extended legs preventing adequate lateral flexion of the body, insert a finger into both groins of the body and apply gentle traction. * Try to bring down a leg by applying pressure in the popliteal space of the posterior leg and flexing it across the fetal abdomen and delivered by a backwand and outward movement. ## **EXTENDED ARMS (CLOUSET MANOUVRE)** * Grasp the baby by the pelvis and apply downward traction so that the scapular can be seen, then rotate the body keeping the back uppermost. This brings the posterior arm around under the symphysis pubis. She then delivers spontaneously; if not splint the humerus and draw the fore arm over the baby’s face. Then rotate the body back again still keeping the back uppermost to bring the posterior arm anteriorly and deliver as before. ## **EXTENDED HEAD** * If the hair line does not appear after allowing the baby to hang by its own weight for one minute, the head is probably extended. ## **MAURICEAU SMELLIE VEIT MANDUURE** * This involves jaw flexion and shoulder traction. Place astride over left fore arm and pass left hand into the vaging. Place middle finger well back into baby’s vaginemouth, put first and 3rd fingers on the mala bones. * With the right hand, grasp the baby’s shoulders. * Placing the middle finger against. the occipit flex the head applying pressure on the occiput while putting down the jaw. * The head should now enter the pelvis and when the hair line is seen, apply shoulder traction - first downward, and then outward and upwards. * When the nose and mouth are free, clear the airways and deliver vault slowly as before. # Dangers Of Breech - To The Baby # 1. Intracranial Injury (Both intracranial haemorrhage and oedema) Due to rapid passage of the head through the pelvis with sudden compression and sudden release. ## # Also moulding is in an upward direction which predisposes to tentorial tear. # 2. Hypoxic compression when head enters the brim, cord compression when head enters the brim. ## # Premature seperation of placenta, before the head is delivered. ## # Premature inspiration by baby before the head is delivered. ## # Constriction ring traps after coming head. - To The Mother * Prolonged Labour * Infection due to interference and prolonged rupture of membranes. * Perineal tear * Anaesthetic risk ## Nerve injury ## Dislocation or fractures ## Bruises ## Visceral injunės - viz ruptured liver, spleen and supra-renals caused by manipulating by grasping the abdomen instead of the pelvis ## Prolonged Labour ## Infection due to interference and prolonged rupture of membranes. ## Perineal tear ## Anaesthetic risk