Malposition and malpresentation

Question 1

What is malposition?

Answer 1

Abnormal position of fetal vertex in relation to maternal pelvi

Question 2

What is the aetiology/RFs of malposition?

Answer 2

fetal head enlarges in the OT position, rotation to OA position with simultaneous flexion. Malpositions in labour include PT, OP and deflexion of head.

Cephalopelvic disporportion (i.e. android pelvis) epidural, inadequate uterine contractions

Question 3

What is the epidemiology of malposition?

Answer 3

10% labours start OP, most correct during labour.

Question 4

What is the history/ examination of malposition?

Answer 4

Prolonged labour.

Abdomen: OP suspect of lower abdomen appears flattened.

Vaginal: determine position through palpation of fetal fontanelles, assess for caput/moulding.

Question 5

What investigations would you do for malposition?

Answer 5

CTG: for fetal wellbeing, frequency of contractions.

Bloods: FBC, G&S (prepare for delivery)

Question 6

What management would you have for malposition?

Answer 6

Labour: hydrate, augment with oxytocin infusion, offer epidural (however this reduces the urge to push therefore increases likelihood of need for obstetric intervention).

Delivery: if failure to progress, and fully dilated but <1/5 palpable abdominally with vertex at/below spines: vaginal delivery with manual rotation / Kelland’s forceps / rotational ventouse delivery. Otherwise offer C section.

Question 7

What are the complications/ prognosis of malposition?

Answer 7

Maternal: exhaustion, risks of obstetric intervention.

Fetal: distress, complications of instrumental deliver.

PGX good – 75% OP positions spontaneously rotate to OA.

Question 8

What is malpresentation?

Answer 8

Any presentaiton where presenting part is not the fetal vertex.

Question 9

What is the aetiology/RFs of malpresentation?

Answer 9

Associated with fetal maternal factors that affect rotation.

Maternal: plcaental site abnormalities, abstructed lower segment (fibroids, pelvic abnormalities) grand multiparity (uterine laxity).

Fetal: multiple gestation, premature, fetal malformations, PHDRMN, macrosomia.

Question 10

What is the epidemiology of malpresentation?

Answer 10

3-4% breech at term, transverse lie 0.3%, face 0.0002%, brow 0.001%, compound 0.1%.

Question 11

What is the history/ examination of malpresentation?

Answer 11

Asymptomatic, detected on examination

· Breech: ABDO palpable head at fundus, soft breech in pelvis. VAG: soft presenting part, ischial tuberosities, anus or genitalia felt. Footling breech: foot seen through cervix.

· Transverse lie: ABDO: no presenting part in pelvis, uterus appears wide, fundal height low. VAG: no presenting part in pelvis

· Face: VAG facial landmarks felt.

· Brow: VAG supraorbital risges and base of nose felt.

Question 12

What investigations would you do for malpresentation?

Answer 12

USS to confirm lie

Question 13

What management would you have for malpresentation?

Answer 13

· Breech: ECV attempred after 37wk.

· Persistent breech: recommend C section

· Transvers lie: requires C section, ECV may be attempted.

· Brow: If persistent or second stage, deliver by C section

· Fact: mentoposterior position delivered by C section, mentoanterior position may atempt vaginal.

· Compound: fetal arm alongside head is the most common – manage expectantly

Question 14

What are the complications/ prognosis of malpresentation?

Answer 14

Maternal: morbidity resulting from operative delivery, prolonged/obstructed labour, uterine rupture (especially transverse) PPH, high perineal injury,

Fetal: perinatal mortality or morbidity due to difficult delivery, prematurity, congenital abnormalities). Cord prolapse is more common -> asphyxia.

PGX depends on aetiology, presentation and timeliness of management plan.