yMalpresentation

Occipito-posterior

• most common abnormal presentation

• foetal neck usually deflexed

• larger diameter head presented to maternal pelvis

• may prolong labour / difficult delivery

• options

  • long labour but SVD

  • manual rotation to OA

  • rotational / posterior ventouse

  • mid-cavity forceps / Keillands rotational forceps

  • Caesarean Section

Face presentation

• 1:500

• head is hyperextended

• chin presents

• if mento-anterior usually flexes to SVD

• if mento-posterior can try manual rotation / rotation forceps but often LSCS

• if chin posterior then vaginal delivery not possible

Brow presentation

• 1:2000

• rarely persists

• vaginal delivery not possible

  • Presenting diameter = 13cm so requires LSCS unless flexes to vertex or extends to face

Breech presentation

• 2nd most common abnormal presentation

• presenting part thinner than head -

• perinatal death rate increased 4x

• can be delivered vaginally or LSCS

• Assisted breech - no pulling

  • breech visible at introitus

  • bring down one and then other leg

  • keep sacrum anterior

  • rotate anterior shoulder posterior and vice versa (Lovsets manoeuvre)

  • finger in cubital fossa - bring down arms

  • allow to hang / head to descend

  • once mouth visible finger in mouth to control delivery of head (Mauriceau-Smellie-Veit) or (Burns-Marshall) hold ankles

• Breech extraction - pulling

  • second twin / fetal distress

  • at LSCS

  • hand in uterus / grab ankle down or fingers onto anterior iliac spines

• factors

  • prematurity

  • congenital anomalies

complications

• nerve damage due to stretching of the brachial plexus

• brain damage due to anoxia

  • cord compressed by foetal head when umbilicus delivered

• worse outcome in primigravidas

variants

• Extended 65%

• Flexed 25%

• Footling 10%

• frank breech

  • hips flexed, knees extended

• complete breech

  • hips and knees flexed - 'sitting' foetus

• footling presentation

  • Single or double

Treatment options

• risk a breech delivery

• external cephalic version (usually at 37-38 weeks)

• caesarean section (transfers risks to mother from foetus)

Shoulder

• transverse or oblique lie

• should be delivered by caesarean section unless second twin

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