Malpresentation/Malposition

Question 1

define malpresentation

Answer 1

the presenting part is not the vertex so includes the face, brow, shoulder and compound presentations and transverse lie.

Question 2

define malposition

Answer 2

the incorrect positioning of the vertex so includes, OP, acynclitic or slight deflexion of the head

Question 3

what is breech

Answer 3

a malpresentation or variant of normal presentation

Question 4

why is presentation important?

Answer 4

in vertex presentation the presenting part is typically a sphere (9.5x9.5cm) which allows:
production of equal uterine contractions
production of equal cervical dilatation (with a well fitting PP)
the membranes will remain intact for longer
the cord will not prolapse

Question 5

maternal factors causing malpresentation

Answer 5

uterine abnormalities (septum, bicornate)
pelvic mass
pelvic shape
anticonvulsant therapy
drug/alcohol abuse
multiparity

Question 6

fetal factors causing malpresentation

Answer 6

IUGR
IUFD
congenital abnormalities: anencephaly, hydrocephalus, myelomeningocele, prader-willi syndrome

Question 7

materno-fetal factors causing malpresentation

Answer 7

preterm delivery, placental position, multiple pregnancy, previous history of malposition, polyhydramnios, oligohydramnios

Question 8

What is the correct term for face presentation?

Answer 8

mento anterior position, submentobregmatic diameter

Question 9

what is the correct term for brow presentation?

Answer 9

occiptiomental diameter.

Question 10

what is the most frequent malposition?

Answer 10

OP

Question 11

what are the risk factors for OP?

Answer 11

nulliparity and maternal age over 35

Question 12

how is OP diagnosed in pregnancy?

Answer 12

abdominal palpation
abdomen appears flattened
saucer shaped depression below umbilicus 
fetal back felt away from the midline
fetal limbs easily felt
fetal head usually high
FHR heard high or at flank
USS

Question 13

what is short rotation?

Answer 13

15% cases occiput rotates through 45 degrees into the hollow of the sacrum
head descends into the lower pelvis in this position
this is direct/persistant OP
associated with anthropoid pelves

Question 14

what is long rotation?

Answer 14

65% cases fetal head descends with some degree of flexion
occiput rotates in mid pelvis through 135 degrees to lie behind symphysis pubis
delivery as OA
increased incidences due to use of oxytocics to amplify uterine contractions

Question 15

how to optimise fetal position antenatally?

Answer 15

hands and knees
gorilla stomp
pelvic rocking
avoid soft chairs for long periods of time
sitting astride dining room chair

Question 16

what comfort measures can you do for an OP position?

Answer 16

counter pressure
heat/cold packs
bath or shower
movement, dancing, swaying, walking, on birth ball

Question 17

how can you help baby turn in labour?

Answer 17

early diagnosis
exaggerated simms position
left lateral with elevated right leg
delay ROM for as long as possible
upright positions - pool or birth ball is best
??epidural

Question 18

complications surrounding persistent OP

Answer 18

Lengthens labour by 1 hour for Multiparous and 2 hours for Primiparous – fetal and maternal distress
Increased pain during labour – back pain and iliac fossa pain especially
Prolapsed cord- ill fitting presenting part and early SROM.
Retention of urine (sinciput presses the urethra and bladder neck against symphysis pubis)
Shape of maternal pelvis/coccyx and fetal spine/occiput makes rotation problematic
Reduces natural mechanism’s ability for flexion (pelvis bones and muscles)

Question 19

complications of OP

Answer 19

Increased pain especially in the back
Prolonged latent phase
Deep transverse arrest
Increased use of pharmacological anaesthesia/analgesia
Prolonged 1st and 2nd stage
Increased moulding and caput (=misdiagnosis of PP)
Premature urges to push before full dilatation (maternal exhaustion)
Oedema to the cervix due to premature pushing
Increased chance of instrumental delivery
Increased chance of trauma to the vaginal tract
Psychological trauma

Question 20

role of the midwife with an OP positioned baby

Answer 20

linking the clues

informing mother of pain relief and coping mechanisms