F E TA L M A L P R E S E N TAT I O N

and MAL P OS I T I ON
 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
Kneeling 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
65-70% of breech babies feet beside the bottom.
are in the frank breech
position.
 Types of Breech Presentation
Footling Breech Kneeling Breech
One or both feet come The baby is in a kneeling
first, with the bottom at a
higher position. This is rare position, with one or both
at term but relatively legs extended at the hips
common with premature and flexed at the knees.
fetuses. This is extremely rare.
 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 EVC fails or is not
advisable, deliver by caesarean section.
 Management

Attempt external version if:

Breech presentation is present at or after 37
weeks
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, fetal
death).
 Management
VAGINAL BREECH DELIVERY. A vaginal
breech delivery by a skilled health care
provider is safe and feasible under the
following conditions:
- complete or frank breech
- adequate clinical pelvimetry
( measuring the size of female pelvis)
- fetus is not too large
- no previous caesarean section for
cephalopelvic disproportion
- flexed head.
 Management
CESAREAN SECTION for breech
presentation. A cesarean section is safer
than vaginal breech delivery and
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
In a transverse lie, a
fetus lies horizizontally 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

• If an infant is preterm and smaller than

usual, an attempt to turn the fetus to a
horizontal lie may be made.
• Most infants in transverse lie must be
born by cesarean birth, however,
because they cannot be turned and
cannot be born normally form in
position.
 Types of
Malpresentation
SINCIPUT FACE
The sinciput presentation The face presentation is caused
occurs when the larger by hyper-extension of the fetal
diameter of the fetal head is head so that neither the occiput
presented. Labor progress is nor the sinciput is palpable on
slowed with slower descent of vaginal examination.
the fetal head.
 Management
In the chin-anterior In the chin-posterior
position position, however, the
prolonged labor is fully extended head is
common. blocked by the sacrum.
Descent and delivery of This prevents descent
the head by flexion and labor is arrested.
may occur.
 Management
Chin-Anterior Position Chin-Posterior Position
If the cervix is fully If the cervix is fully
dilated: dilated:
 Allow to proceed with  Deliver by caesarean
normal childbirth; section.
 If there is slow progress If the cervix is not fully
and no sign of dilated
obstruction, augment
labor with oxytocin;  Monitor descent, rotation
 If descent is and progress. If there
are signs of obstruction,
unsatisfactory, deliver by deliver by caesarean
forceps. section.
If the cervix is not fully
dilated and there are no *Do not perform vacuum
signs of obstruction: extraction for face
 augment labor with presentation.
oxytocin.
 Types of Malpresentation

BROW
The brow
presentation is
caused by partial
extension of the
fetal head so that
the occiput is
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.
 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
Nursing Mgt
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.
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 technique s 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.
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 Occipitotransverse Position
Arrested labor may occur It is the incomplete
when the head does not rotation of OP to OA results in
rotate and/or descend. the fetal head being in a
Delivery may be horizontal or transverse
complicated by perineal position (OT).
tears or extension of an
episiotomy.
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 flexion.
(C)Internal 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
laceration of the • secondary arrest of
perineum. dilatation
• arrest of descent
D iiaagngnososiiss::
wer part of the abdomen is
AAbbdomidominnaall
flattened, fetal limbs are palpable anteriorly and the fetal flank.
eexxaamiexamination
Vaginal minnaattiionon––the
theloposterior 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, deliver by
caesarean section.
• If the membranes are 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, augment labor
with oxytocin.
• If the cervix is fully dilated but there is no
descent in the expulsive 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
station and -2 station, symphysiotomy, perform
Delivery by Vacuum caesarean section;
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 Vacuum extraction - Provides
a means of rotating the fetal traction to shorten the second
head. stage of labor.
Risks: fetal Risks: newborn
ecchymosis(discolourationo cephalhematoma, retinal
f skin) or edema of the hemorrhage and intracranial
face, transient facial hemorrhage.
paralysis, maternal
lacerations, or episiotomy
extensions.
 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.
QUIZ
TIME!!!!!!!!!!!!