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yMalpresentation


Occipito-posterior

  • most common abnormal presentation

  • foetal neck usually deflexed

  • larger diameter head presented to maternal pelvis

  • may prolong labour / difficult delivery

  • options

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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