MAL-POSITIONS AND MAL-

PRESENTATIONS
 MAL-POSITION
• DEFINITION;
• A mal-position is one where the fetal head is
presenting but not as a well-flexed vertex with
the occiput in the anterior quadrant.
 MAL-POSITION CONT.
• OCCIPITO-POSTERIOR POSITION (OPP);
• An occipito-posterior position is a mal position
of vertex presentation.
• Thus, the vertex is presenting, but the occiput
lies in the posterior instead of the anterior of
the pelvis
• Occipito-posterior positions are the most
common type of mal position of the occiput.
 MAL-POSITION CONT.
INCIDENCE;
• It occurs in approximately 10% of labours
• When there is a failure of the internal rotation
before delivery the persistent OPP results. This
occurs in 5% of deliveries.
CAUSES;
• Direct cause is unknown
 MAL-POSITION CONT.
Associated causes include;
• Android pelvis: the fore pelvis is narrow and the occiput
tends to occupy the hind pelvis which is more roomy.
• Anthropoid pelvis: the oval shape with the narrow
transverse diameter favours a direct occipito-posterior
position.
Other causes suggested are:
- Pendulous abdomen
- Flat sacrum
- Anterior placenta
 ANC DIAGNOSIS
• Abdominal examination
i. On inspection;
• The abdomen appears flattened or slightly depressed
just at or below the umbilicus
Note:
 This dip is created by the drip between the head and
the lower limbs of the foetus (saucer-like depression)
 The outline created by the high unengaged head can
look like a full bladder
 ANC DIAGNOSIS
ii. On palpation
• The foetal head is high
• OPP is the commonest cause of non-engaged head in
late pregnancy in a primigravida. This is because the
large presenting diameter, the occipitofrontal
(11.5cm), is not likely to enter the pelvic brim until
labour begins and flexion occurs
• The breech can be easily palpated at the fundus but
the back is difficult to palpate because it is well out in
the side (flank) of the mother.
 ANC DIAGNOSIS
• If the occiput is markedly posterior, the high
heads feels small since it is palpated near the
bitemporal diameter
• Foetal limbs are felt as small knobs on both
sides of the uterus (both sides of the midline)
• The occiput and the sinciput are on the same
level
 ANC DIAGNOSIS
iii. On auscultation
• The foetal heart sounds are often heard just
below the umbilicus. It can be heard in the
midline because the chest is thrust forward. If
the heart sound are heard at one side of the
mother it suggests that the back is directed to
that side.
 MGT DURING ANC
• It has been suggested that active changes in
maternal posture can rotate the occiput to the
anterior position. For example:
• Knee-chest position several times a day (this is
yet to be confirmed by research)
 DIAGNOSIS DURING LABOUR

• The woman may complain of continous and

severe backache which worsens with
contractions
• In early labour it may be difficult to reach the
presenting part
• Membranes may rupture early (because the
large presenting diameters which is irregularly
shaped does not fit well into the cervix)
 DIAGNOSIS DURING LABOUR

• Descent of the head can be slow even when

there are good contactions
• The woman may have strong desire to push
early in labour (because the occiput is
presenting on the rectum)
 DIAGNOSIS DURING LABOUR CONT.

On vaginal examination:
- The findings will depend on the degree of
flexion of the foetal head
- Palpation of the anterior fontannalle in the
anterior part of the pelvis is the main
diagnosis of occitoposterior position (This
may be difficult if caput succedaneum is
present)
 DIAGNOSIS DURING LABOUR CONT.

When the head is partially or well-flexed the

anterior fontanelle is just within reach at the
back
- With a deflexed head, the anterior fontanelle
is almost central and can easily be recognized
by its shape and size unless there is caput
 CARE DURING LABOUR
(MANAGEMENT OF LABOUR)

• A. Management in the Health centre or

community
• The midwife should:
- Explain condition to the client
- Reassure client
- Check temperature, pulse, respiration, blood
pressure (vital signs) and hydration
 CARE DURING LABOUR
(MANAGEMENT OF LABOUR)
- Perform abdominal examination to;
• Assess presentation, lie, position

• Check foetal heart rate

- Do vaginal examination to determine the cervical

dilatation and adequacy of the pelvis
 Care during labor
(Management of labor) cont.
• Give adequate analgesia
• Massage client’s sacral region to relieve pain during
contractions
• If cervix is full and the pelvis is adequate and the head is
rotated to the antero-posterior position then;
- Conduct normal delivery
- Refer client if there is disproportion and deep transverse arrest
- Deliver with episiotomy if it is face to pubis
- Refer client if there is disproportion and deep transverse arrest
 B. Management in the hospital

• First stage of labour;

• The midwife should:
- Reassure the client
- Provide physical support and other comfort
measures such as; cleaning client’s face and hands
with towel and massaging the back.
 B. Management in the hospital

Encourage client to adopt a comfortable position for

example, ALL-FOURS as this relieve her of pain and
it may also help rotation of the foetal head
- Encourage client to do breathing exercises to
relieve and prevent pushing before cervix is fully
dilated due to pressure on the sacrum.
- Check foetal heart rate
 Management in the hospital cont.

• Check uterine contractions

• Do vaginal examination
• Inform doctor
- IV fluid may be set up to prevent dehydrations if
labour is prolonged
- Adequate analgesia is given
- If contractions are weak and ineffective or
incoordinate, syntocinon drip is set to correct
them.
 Second stage of labour

• Vaginal examination must be done to confirm full

dilatation of the cervix. (This is done because
moulding and formation of a caput succedaneum
may bring the vertex into view while anterior lip of
the cervix remains)

• If the head is not visible at the onset of second stage,

the midwife should encourage the woman to be in
the upright position
 Second stage of labor cont.

Note: The position may shorten the length of

the second stage
- Labor may be augmented with oxytocin drip if
the contractions are weak and ineffective
- Check fetal heart rate after every contraction
- Check maternal hydration, blood pressure and
pulse ¼ hourly and respiration ½ hourly
 Second stage of labor cont.

Check the woman’s emotional state continuously

- If the cervix is fully dilated and if the head is
more than 3/5 palpable above the symphisis
pubis, the woman is prepared for caesarean
section
- If the head is 1/5 or 0/5 above the symphysis
pubis, the woman is delivered by vacuum
extraction of forceps.
 Possible course and outcome of labor

1.Long internal rotation

2.Short internal rotation – persistent occipito-
posterior position
3.Deep transverse arrest
4.Conversion to face presentation
5.Conversion to brow presentation
 OUTCOME OF OPP
Mechanism of Right Occiptoposterior Position
1. LONG ROTATION OF OPP
• The lie is longitudinal
• The attitude of the head is deflexed
• The presentation is vertex
• The position is right occipitoposterior
• The denominator is the occiput
 OUTCOME OF OPP CONT.
• The presenting part is the middle or anterior
area of the left parietal bone
• The occipitofrontal, 11.5cm lies in the right
oblique diameter of the pelvic brim. The
occiput points to the right sacroiliac joint and
the sinciput to the left iliopectineal eminence.
 OUTCOME OF OPP CONT.
• Flexion – descent takes place with increasing flexion.
The occiput becomes the leading part, Internal
rotation of the head – the occiput reaches the pelvic
floor first and rotates forwards 3/8 of a circle along
the right side of the pelvis to lie under the symphysis
pubis. The shoulder follow, turning 2/8 of a circle
from the left to the right to the right oblique
diameter.
• Crowning – The occiput escapes under the
symphysis pubis and the head is crowned
 OUTCOME OF OPP CONT.
• Extension – the sinciput, face and chin sweep the
perineum and the head is born by a movement of
extension
• Restitution – the occiput turns 1/8 of a circle to the
right and the head realigns itself with the shoulders
• Internal rotation of the shoulders – the shoulders
enter the pelvis in the right oblique diameter; the
anterior shoulder reaches the pelvis floor first and
rotates forward 1/8 of a circle to lie under the
symphysis pubis
 OUTCOME OF OPP CONT.
• External rotation of the head – at the same
time the occiput turns a further 1/8 of a circle
to the right
• Lateral flexion – the anterior shoulder escape
under the perineum and the body is born by a
movement of lateral flexion.
 2. Short internal rotation
(persistent occipitoposterior position)

• Persistent occipitoposterior position is a term

that means that the occiput fails to rotate
forward
• The sinciput reaches the pelvic floor first and
rotates forward instead of the occiput
• The occiput goes into the hollow of the sacrum
• The baby is born facing the pubic bone (face to
pubis)
 CAUSES OF PERSISTENT OPP

• Failure of flexion – The head descends without increased

flexion and the sinciput becomes the leading part. It
reaches the pelvic floor first and rotates forward to lie
under the symphysis pubis

Diagnosis:
In the first stage of labour;
• Head is deflexed
• Foetal heart can be heard in the flank or in the midline
• Descent is slow
 In the second stage of labour

• There is a delay
• On vaginal examination the anterior fontanelle is
felt behind the symphysis pubis (this may be
masked by caput succedaneum)
• Pinna of the ear is felt pointing towards the
mother’s sacrum (indicating a posterior position)
• Dilatation of the anus and gaping of the vagina
occurs while the foetal head is not well visible and
 In the second stage of labour

• The broad parietal diameter distends the

perineum and may cause excessive bulging (due
to the long occipito-frontal diameter)
• As the head advances, the anterior fontanelle
can be felt behind the symphysis pubis;
• The baby is born facing the pubis
• Upward moulding is present with caput
succedaneum on the anterior part of the parietal
bone.
 Management at delivery

• The sinciput will first emerge from under the

symphysis pubis as far as the root of the nose
and
• The midwife maintains flexion by restraining it
from escaping further than the glabella
• This allows the occiput to sweep the perineum
and be born
 Management at delivery

• The head is then extended by grasping and

bring the face down from under the symphysis
• The midwife should watch for signs of rupture
in the centre of the perineum. (This is because
perineal trauma can occur due to the large
presenting diameters)
 3. DEEP TRANSVERSE ARREST
(DTA)

Characteristics
- The head descends with some increase in
flexion
- The occiput reaches the pelvic floor and
begins to rotate forward
- Flexion is not maintained and
- Occipitofrontal diameter becomes caught at
the bispinious diameter of the outlet
 CAUSES OF DTA

• Arrest may be due to weak contractions, a straight sacrum or a

narrow outlet

Diagnosis
- The saggital suture is found in the transverse diameter of the
pelvis
- Both the anterior and the posterior fontanelles are palpable
- Neither sinciput nor occiput leads
- The head is deep in the pelvic cavity at the level of the ischial
spines although the caput may be lower
- There is no advancement of foetal head
 MANAGEMENT OF DEEP TRANSVERSE
ARREST

The mid wife should:

• Explain condition to the mother and reassure her
• Inform the woman if operation will be done
• Prepare client for operative delivery if it is required
• Encourage and support client to change positions
(this will help to overcome the urge to bear down)
• Encourage the woman to do deep breathing
exercise
• Analgesia or anaesthesia is given
MANAGEMENT OF DEEP TRANSVERSE ARREST

The woman may be delivered by;

i. Vaccum extraction
ii. Forceps to rotate the head to an occipito
anterior position before delivery
iii. Caeserean section
 4. CONVERSION TO FACE OR BROW
PRESENTATION

• When the head is deflexed at the onset of

labour extension occasionally occurs instead
of flexion
• If extension is complete, a face presentation
results.
• If extension is incomplete, the head is arrested
at the brim, the brow presenting
 Complications of occipitoposterior position

A. Maternal
1.Prolonged labour: This may be due to a deflexed
head, over efficient uterine contractions and
slightly contracted pelvis
2. Maternal distress
3. Retention of urine
4.Early distension of the perineum and dilation of
the anus
 Complications of occipitoposterior position

5.Trauma to the soft tissues

6.Infection (due to early rupture of membranes)
7.Operative intervention and risk of anaesthesia
8.Obstructed labour
- This may occur when the head is deflexed or
partially extended and becomes impacted in
the pelvis.
 Complications of occipitoposterior position

B. Foetal/Neonatal

1.Neonatal trauma (associated with forceps or

vacuum delivery)
2.Cord prolapsed (this occurs because with high head
and unfitting presenting part, the membranes tend
to rupture early and the cord may prolapse)
3.Foetal distress
4. Infection (due to early rupture of membranes)
 Complications of occipitoposterior position

5. Intracranial damage/cerebral harmorrhage.

This will occur due to:

-Upward moulding of the foetal skull resulting in

falx cerebri being
pulled away from the tentorium cerebella
-Compression due to larger presenting diameters
-Chronic hypoxia due to prolonged labour
 5. FACE PRESENTATION

• Face presentation is a condition in which the attitude of

the head is one of a complete extension, the occiput of
the foetus will be in contact with its spine and the face
will present .

• In face presentation the head and spine are fully extended

but the limbs are flexed, so that the foetus lies in the
uterus in a S-shaped attitude, the occiput against its
shoulder blades and the face directly over the internal as:
Incidence 1:500
 TYPES OF FACE PRESENTATION

1)Primary face presentation – the face presents before labour.

This is rare.
2)Secondary face presentation – develops during labour from
vertex presentation
CAUSES
a)Primary face presentation
 Congenital abnormalities
– Anencaphaly – it occurs because there is no vertex to present
– Tumour of the neck e.g. foetal goiter (rare) – the head cannot flex
– A normal foetus can actively hold its head extended and even after
delivery the infant may keep its head in an exaggerated extension for
sometime
 TYPES OF FACE PRESENTATION
CONT.
b) Secondary face presentation
i. Anterior obliquity of the uterus (pendulous
abdomen)
• The uterus of multiparous women with slack
abdominal muscles and a pendulous abdomen will
lean forward and change the direction of the uterine
axis. This causes the frontal buttocks to lean forward
and the force of the contractions to be directed in a
line towards the chin rather than the occiput,
resulting in extensions of the head.
 TYPES OF FACE PRESENTATION
CONT.
ii.Contracted pelvis
• Flat pelvis – the head enters in the transverse
diameter of the brim and the parietal eminence may
be held up in the obstetrical conjugate, the head
becomes extended and face presentation results.
iii. Android pelvis – the pariety eminence may be
caught up in the sacrocotyloid dimension. The
occiput does not descend, the extend resulting in
face presentation.
 TYPES OF FACE PRESENTATION
CONT.
iv. Multiple pregnancy
v. Mal position especially of the second twin

vi. Polyhydramnios
• If the vertex is presenting and the membranes
rupture spontaneously, there is fluid and this
may cause the head to extend as it sinks into
the lower uterine segment.
 ANTENATAL DIAGNOSIS
(DIAGNOSIS DURING PREGNANCY)

• Face presentation is not easily diagnosed in

pregnancy. It is rare because it usually develops
during labour in majority of cases
• Face presentation should be suspected if a deep
groove is felt between the foetal head and back
• Foetal heart sounds are heard through the
anterior chest wall on the sides where the limbs
are palpated
 ANTENATAL DIAGNOSIS
(DIAGNOSIS DURING PREGNANCY)

• Foetal heart sounds may seem unusually loud

and clear when the position is mentor anterior
and are more difficult to hear when the
position is mentoposterior because the chest
is in contact with maternal spine
• Ultrasound scan may disclose an unsuspected
face presentation
 DIAGNOSIS OF LABOUR
(INTRAPARTUM DIAGNOSIS)

A). On abdominal examination:

1.The occiput feels prominent, with a groove
between head and back, but it may be
mistaken for a sinciput
2.The limbs may be palpated on the side
opposite to the occiput
 DIAGNOSIS OF LABOUR
(INTRAPARTUM DIAGNOSIS)

3.Foetal chest is on the same side as the limbs

4.In mentoposterior position the foetal heart is

difficult to hear because the foetal chest is in
contact with the maternal spine
 On vaginal examination
·The presenting part is high, soft and irregular
·The orbital ridges, eyes, nose and mouth with
gums may be felt when the cervix is
sufficiently dilated
·The foetus may suck the examining finger
 On vaginal examination
• Note: As labour progresses the face becomes
oedematous and this makes it difficult to
distinguish facial land marks on vaginal
examination and distinguish it from the anus.
The midwife should take care not to injure the
eyes with examining finger.
 V/E CONT.
• The midwife can differentiate between the
mouth and the anus with the underlisted
point in mind
Ø The mouth sucks
Ø The anus grips
Ø There are hard gums in the mouth
Ø The mouth may be opened
 V/E CONT.

• Once a face presentation is diagnosed, it is

important to determine the position of the
chin to note if it is anterior or posterior.
A posterior face presentation will lead to
obstruction unless it rotates to the anterior
position
There are 6 positions in a face presentation

These are;

1.Right mentoposterior (RMP) – The chin points

to the right sacroiliac joint
2.Left mentoposterior (LMP)) – The chin points
to the left sacroiliac joint
3.Right mentolateral (RML) – The chin is
directed towards the right side of the pelvis
There are 6 positions in a face presentation

4.Left mentolateral (LML) – The chin is directed

towards the left side of the pelvis
5.Left mentoanterior (LMA) – The chin points to
the left iliopecctineal eminence (This is the
commonest)
6.Right mentoanterior (RMA) – The chin points
to the right iliopectineal eminence
Mechanism of a left mentoanterior position

• The lie is longitudinal

• The attitude is one extension of the head

• The presentation if face
• The position is left mentoanterior
• The denominator is mentum
• The presenting part is left malar bone
 MECHANISM CONT.
1. Descent: descent takes place with increasing
Extension. The mentum becomes the leading part.
The submento bregmatic (9.5cm) is the engaging
diameter

2. Internal rotation of the head

· The chin reaches the pelvic floor and rotates 1/8 of a
circle
· The chin escapes under the symphysis pubis and it is
born
 MECHANISM CONT.
Flexion
• With further descent, the face is born by
flexing the sinciput, vertex and occiput sweep
the perineum and the head is born

4. Restitution
• The chin turns 1/8 of a circle to the woman’s
left
 MECHANISM CONT.
5. Internal Rotation of the shoulder
• The shoulders enter the pelvis in the left oblique diameter
• The anterior shoulder reaches the pelvic floor first and
rotates forward 1/8 of a circle along the right side of the
pelvis (it lies in the anterior posterior diameter of the
outlet)
6. External Rotation of the head
• This occurs at the time of internal rotation of the
shoulders
• The chin moves a further 1/8 of a circle to the left
 MECHANISM CONT.
7. Lateral flexion
• The anterior shoulders escapes under the symphysis
pubis
• The posterior shoulder sweeps the perineum
• The body is born by a movement of lateral flexion

• Moulding in face presentation

• The sub mento bregmatic is compressed causing the
occipito frontal diameter to increase. The shape of the
face is described as DOLICEPHALY.
Mechanism of Mento Poseterior Position

• When the chin is posterior, it has to rotate 3/8 of a circle to

come under the symphysis pubis and be born normally
• Sometimes the fetal head is not completely extended and
the sinciput may reach the pelvic floor first causing the chin
to go into the hollow of the sacrum. This is termed
persistent mento posterior and the body cannot be born
vaginally as the neck is not long enough for the chin to
reach the pelvic floor
• The chin becomes arrested in the hollow of the sacrum and
labour becomes obstructed
 MANAGEMENT

Community/Clinic/Health Centre
The midwife should:
• Explain the condition and procedures to the client
• Ensure privacy
• Check pulse, temperature, respiration and blood
pressure
• Check client’s hydration
• Test urine for ketones
• Set up IV fluid
 MANAGEMENT

• Assess the woman’s emotional state and

coping ability
• Check foetal heart rate, listen to the foetal
heart rate during and immediately after a
contraction
• Perform abdominal examination
• Do vaginal examination and refer client to the
hospital
 HOSPITAL MGT

The midwife should:

• Explain the condition to the client
• Do general examination
• Observe mother closely:
• Check temperature, pulse, respiration and
blood pressure
 HOSPITAL MGT

• Check hydration
• Inform doctor
• IV fluid set up
• Abdominal examination is done
• Vaginal examination is done
 HOSPITAL MGT CONT.

• Immediately after membranes have ruptured,

a vaginal examination should be done to
ascertain
- Cervical dilatation
- Prolapse of cord
- Descent of the presenting part
 HOSPITAL MGT CONT.

The doctor looks for the underlying cause and this determines
the care performed on account of
a.If the chin-is in an anterior position and cervix is fully dilated
• The woman is allowed to have a spontaneous delivery.
• If there is slow progress and no signs of obstruction, labour is
augmented with oxytocin. If descent is unsatisfactory, forceps
delivery may be done.
b.If chin-is in a posterior position
• Caeserean section is done
• The midwife should prepare the woman physically and
psychologically
 Delivery of the face

Mento anterior Position

• The midwife should:
Ø Hold back the sinciput posteriorly and maintain extension until
the chin escapes under the symphysis pubis
Ø The occiput is then allowed to emerge posteriorly by sweeping
the perineum. By this technique
Ø The submentovertical diameter of (11.5cm) distends the vaginal
oriffice instead of the mentovertical diameter of (13.5cm)
• Because the perineum is also distended by the bi-parietal
diameter (9.5cm), an episiotomy may be performed to avoid
extensive perineal lacerations.
 COMPLICATION

Maternal
1.Prolonged Labour
2.Maternal trauma
- Perineal laceration
3.Infection (puerperal sepsis). This will occur
due to repeated vaginal examination and
surgical interference (C/S)
 COMPLICATION

• Foetus/Baby
1.Infection
2.Cerebral haemorrhage
3.Cord prolapse leading to anoxia
4.Injury to eyes

• Note: The midwife forewarns the mother about the

bruised appearance of the baby’s face and reassure
mother that the face will become normal within few
days.
 6. BROW PRESENTATION

• This is the presentation in which the foetal head is partially

extended with the frontal bone, which is bounded by the
anterior fontannelle and the orbital ridges lying in the pelvic
brim.
• The presenting diameter in brow presentation is
mentovertical (13.5cm), which exceeds all diameters in an
average-sized pelvis.

Incidence
• Rare – 1 in1,000 deliveries (approximately)
 CAUSES

Same as the causes of secondary face

presentation:

Ø Anterior obliquity of the uterus (uterus turned

side ways)
Ø Contracted pelvis – flat pelvis, android pelvis
Ø Polyhydramnios
Ø Congenital abnormality
 CAUSES

Lax uterus
Ø Multiple pregnancy
Ø Prematurity
Ø During the process of extension from a vertex
presentation, the brow will present temporary
and in few cases this will continue to exist.
 Diagnosis

Brow presentation is not usually detected before

the onset of labour
On abdominal Palpation
This head is:
• High
• Appears large, and
• Does not descent into the pelvis despite good
uterine contractions
 Diagnosis

• On vaginal examination
·The presenting part is high and may be difficult to reach
·The anaterior fontannelle may be felt on one side of the
pelvis and the orbital ridges, and possibly the root of
the nose felt at the other side.
Note: A large caput succedaneum may cover these
landmarks if the woman has been in labour for some
hours.
·Ultrasound scan or X-ray will be used to confirm
diagnosis
 MANAGEMENT

In the community/Health centre

· Do general examination
· Check temperature, pulse, respiration and
blood pressure
· Do abdominal examination
- Check foetal heart rate
- Check contractions
 MANAGEMENT

Do vaginal examination
· Take blood for haemorrhage estimation and
blood grouping
· Set up IV fluid e.g. Ringers Lactate and Normal
saline
· Explain condition to the woman and relatives
· Refer client to the hospital with her records
 MANAGEMENT CONT.

In the hospital
• The midwife must inform the doctor immediately
• The mother should be told about the possible outcome of labour
• Temperature, pulse, respiration and blood pressure are checked
• General examination is done
• Abdominal examination is done
- Inspection
- Palpation
- Foetal heart is checked
- Contractions are checked
 MANAGEMENT CONT.

• Vaginal examination is done as soon as

membranes rupture
• If there is no foetal distress, monitoring is
continued for a short while to see if the
extension of the head will convert the brow
presentation to a face presentation
 MANAGEMENT CONT.
Note: Occassionally, spontenous flexion may
occur, and this will result in a vertex
presentation
• If the head fails to descend and brow
presentation fails to change, Caeserean section
is done after the mother’s consent has been
sought.
• The midwife should prepare the client of
surgery
 MANAGEMENT CONT.
• Vaginal delivery is extremely rare and
obstructed labour usually results.
• It is possible that a woman with a large pelvis
and a small baby may deliver vaginally, of a
persistent occipitoposterior position.
However, this is rare and the midwife should
never expect such a favourable outcome.
 COMPLICATIONS

• Maternal
· Obstructed labour
· Maternal distress
· Infection

• Foetal
· Prolapse of cord
· Foetal Distress
· Still birth
 MAL PRESENTATION

• Any presentation other than the vertex is

termed malpresentation.
• The malpresentations are therefore;
 Breech
 Face
 Brow and
 Shoulder.
 BREECH PRESENTATION

• Breech presentation occurs when the foetal

buttock lie in the lower pole of the maternal
uterus
· The lie is longitudinal
· The denominator is the sacrum
· The presenting diameter is the bitrochanteric
which is 10cm
 BREECH PRESENTATION

Incidence
• The incidence of breech presentation at the time of
delivery is 3%.
• In the mid-trimester the frequency is much higher
because the greater proportion of amniotic fluid helps
free movement of the foetus.

• One foetus in four (1:4) will present by the breech at

some stage of pregnancy by the 34th week most of
these foetus have turned so that the vertex presents.
 TYPES OF BREECH PRESENTATION

• 1) Complete or flexed breech

Ø The foetal attitude is one of a complete flexion
Ø The foetus sits over the pelvis with hips flexed
and the feet tucked in close beside the
buttocks

• This is common in multigravidae

COMPLETE BREECH
 2) Footling breech
• One or both feet present below the buttocks
with hips and knee extended
• The feet are lower than the buttocks

• Footling breech is rare but is more likely to

occur when the foetus is preterm.
FOOTLING BREECH
 3)Frank Breech (Breech with extended legs)

• The foetal hips/thighs are flexed and

• Legs are extended at the knees and extended on the
trunk/abdomen (The lie alongside the trunk/abdomen)
• The feet is near the head

• Note: Frank breech is the commonest type of breech

presentation and is common in primigravidae towards
term because their firm abdominal muscles allow only
limited foetal movement. The foetus is therefore
unable to flex its leg and turn to cephalic presentation.
FRANK BREECH
 4) Knee Presentation

• One or both hips are extended and the knees are

flexed
• One or both knees present below the buttocks
Causes of breech presentation
• Often no cause is identified but many of the probable
causes of breech presentation are associated with
conditions which either restrict the foetus to turn
freely in the uterus, or allow the foetus to change its
presentation frequently because there is excessive
space within the uterus.
 Causes of breech presentation

• Causes which inhibit freedom of foetal

movement include:
• Primigravidae with firm abdominal and
uterine muscles
• Uterine fibroids (if interferes with the activity
of the foetus or are situated in the lower
uterine segment).
• Oligohydramnios
 Causes of breech presentation

• Placenta praevia
• Contracted pelvis (because foetal head is
unable to enter the pelvic brim) which restrict
foetal activity to prevent engagement in the
pelvis e.g. hydrocephalus
• Multiple pregnancy (limits the space available
for each foetus to turn)
 Causes of breech presentation

cont.
• Causes associated with excessive space in the
uterus include:
• Polyhydmnios (due to distension of the
uterine cavity because of excessive amounts
of amniotic fluid
• Grandemultiparity
 Causes of breech presentation
cont.
Foetal Causes
• Foetal death
• Poor foetal growth
• Preterm labour
• Short umbilical cord (this restricts foetal
movement)
• Congenital abnormality (hydrocephaly)
 Diagnosis of Breech presentation

• Antenatal Diagnosis
History
• A history of previous breech deliver
• The woman may give a history of discomfort
under ribs especially at night due to the presence
of the hard foetal head on the diaphragm
• She may also give a history of kicking in the lower
pole of the uterus
 Diagnosis of Breech presentation
cont.
• Abdominal examination
On palpation;
• The lie is longitudinal with a soft presentation
• The presenting part feels firm but not hard as
bone
• The presenting part is less rounded than the
head
 Diagnosis of Breech presentation
cont.
• The head is felt in the fundus as a round mass
which may be made to move independently of
the neck by balloting it with one or both
hands.
• If the legs are extended and the baby’s feet
lies under the chin, ballottement cannot be
done.
 Diagnosis of Breech presentation
cont.
• Note: In a primigravidae diagnosis is difficult
because of the firm abdominal muscles. It is
more difficult if the legs are extended and the
breech is deep in the pelvis. This can be
mistaken for the deeply engaged head.
 Diagnosis of Breech presentation
cont.
• Auscultation;
• The foetal heart sound is heard most clearly
above the umbilicus when the breech has not
passed through the pelvic brim.
• When the legs are extended the foetal heart is
heard at a lower level (because the breech
descends into the pelvis easily in extended
legs)
 Diagnosis of Breech presentation
cont.
• Ultrasound scan
• This will show breech presentation
• X-ray examination-this may be done to confirm breech
presention and it also allows pelvimetry to be performed at the
same time.

Diagnosis of breech during labour

Abdominal examination
• Abdominal examination will reveal a longitudinal lie with a soft
presentation which is more easily felt using Pawlik’s grip
• The head can easily be felt in the fundus
 Diagnosis of Breech presentation
cont.
• Vaginal examination
• The breech is felt as soft and irregular with no
sutures palpable
• The anus may be felt
• The hard sacrum will be palpable
 Diagnosis of Breech presentation
cont.
• The genitalia may felt as soft but cannot be
recognized easily because they become
oedematous
• Fresh meconium is seen on the examining
finger (this is diagnostic of breech
presentation)
• In a flexed breech the feet may be palpable
alongside the buttocks
 Diagnosis of Breech presentation
cont.
• The features of the foot which helps to
differentiate it from the hand are
• Toes are shorter than fingers (toe have shorter
digits)
• The toes are all the same length
• The big toe cannot be moved easily as the thumb
• The foot is at right angles to the leg
• The foot has heel but the hand does not have
 ANC MGT OF BREECH PRESENTATION
VERSION

• Version is the practice of turning the foetus in utero

to obtain a more favourable lie or presentation
• Version is turning the foetus in utero, to change a lie
or presentation to one which is more favourable
• Types of Version
1.External Version
2.Internal Version
3.Bi polar Version (Rare)
 External Cephalic Version (ECV)

• External Cephalic Version is the external

manipulation of the foetus on the mother’s
abdomen to turn it to cephalic presentation. It is
done after 37 weeks gestation.
• Indications
1.To convert a breech to a cephalic presentation
when there are no other complications.
2.To correct a transverse lie, usually in a
multigravida.
 External Cephalic Version (ECV)

3. To correct a transverse lie in a second twin.

• Criteria for External Cehalic Version

• Singleton foetus in the third trimester
• An adequate amount of liquor
 Method
Preparation before External Cephalic Version
1.An ultrasound scan is performed to determine
where the placenta is located.
2.The advantages and potential risks of the
procedure is explained to the women.
3.The woman’s temperature, pulse, respiration
and blood pressure are checked and recorded
 Method
4.The women are asked to empty her bladder.
5.She is reassured and encouraged to relax.
6.The midwife assists the woman into a comfortable
supine position.
7.If tocolytic drug will be used then a cannula need
to the sited
• Note Tocloytic drug are drugs used to arrest
threatened preterm labour e g ritodrine
hydrochloride (yutopar), Salbuamol (ventolin)
 Method cont.
8. The foot of the bed may be raised to help release
the breech from the pelvic brim.
9. It is done by a skilled and experienced obstetrician .
10.The breech is moved from the pelvic brim towards
the iliac fossa.
11.The obstetrician exerts gentle pressure on each
pole of the foetus simultaneously to turn it by a
forward summersult method to a cephalic
presentation
 Method cont.
Step:
• The right hand lifts the breech out of the pelvis whiles
the left hand makes the head follow
• Flexion of the head and back is maintained throughout
• The left hand brings the head downwards
• The right hand pushes the breech upwards
• Pressure is exerted on the head and breech
simultaneously until the head is lying at the pelvic brim
 Method cont.
• If this forward turning fails then a backward
summersult is attempted.
10. If the foetus does not turn, the procedure is
stopped and repeated after a few days later
 Method cont.
After the Procedure:
• The foetal heart is monitored
• The woman is encouraged to rest
• The woman is advised to report any vaginal bleeding,
loss of amniotic fluid or uterine contractions.
• Rhesus – negative women have a Kleihauser test
carried out and are given anti –D immunoglobin
because of the risk of foeto-maternal haemorrhage
and subsequent iso-immunization
 Contraindication

Absolute contraindication
• Multiple pregnancy due to risk of cord
accident eg entanglement
• Severe uterine growth retardation
• Severe oligohydramnions
• Foetal abnormality
 Contraindication

• Contraindication to vaginal delivery

• Significant bleeding in third trimester (since
there is a risk of causing further placental
separation and haemorrhage and a
compromise foetus)
• Rhesus-isommunization (due to the risk of
foeto-maternal haemorrhage)
• knot cord- risk of foetal distress.
 Contraindication
cont.
Relative Contraindications
• Uterine abnormality e.g bicornuate uterus
(because a successful outcome is more difficult to
achieve)
• Maternal illness (e.g cardiac disease,
hypertension, diabetes mellitus, thyroid disease)

• This is contraindicated because tocolytic drugs

may be administered
 Complications

Complications are rare and they include

• Placental abruption
• Premature rupture of the membranes
• Cord complications e.g entanglement (or
knotting) of the cord
• Onset of labour
 Complications

• Foeto – maternal haemorrhage

• Negative psychological effects on the mother
if version fails
• External cephalic version is carried out in
maternity units with all the facilities necessary
to deal with any complications which may
arise
 Benefits of external cephalic version

• If external cephalic version is successful it;

• Reduces the incidence of breech presentation
in labour with its associated risk.
• Reduces Caesarean section rate
• Reduces Perinatal mortality and morbidity
associated with vaginal breech delivery
 INTERNAL PODALIC VERSION

• Internal version is inserting the hand into the

uterus, turning the child with one hand in the
uterus and the other on the abdomen.
• Internal podalic version is turning the child to
make the breech present, with one hand in
the uterus and the other on the abdomen. It
is seldom performed.
THE SIX POSITIONS IN BREECH
PRESENTATION
 Mechanism of left sacroanterior position

• The lie is longitudinal

• The attitude is one of complete flexion
• The presentation is breech
• The position is left sacroanterior
 Mechanism of left sacroanterior position

• The denominator is the sacrum

• The presenting part is the anterior (left)
buttock
• The bitrochanteric diameter 10cm enter the
brim in the left oblique diameter
• The sacrum points to the left iliopectineal
eminence
Mechanism of left sacroanterior position cont.

• Compaction (Descent)
1)The breech engages with the bitrochanteric diameter
(10cm) in the left oblique diameter of pelvic brim.
• Descent takes place with increasing flexion of the limbs
2) Internal rotation of the buttocks
- The anterior buttocks reaches the pelvic floor first and is
rotated forwards through 1/8th of a circle and comes to
lie behind (beneath) the symphysis pubis
-The bitrochanteric diameter is now in the anteroposterior
diameter of the outlet
Mechanism of left sacroanterior position cont.

3) Lateral fiexion of the body.

• The anterior buttocks escapes under the symphysis
pubis.
• The posterior are born by sweeps the perineum and
• The buttocks are born by a movement of lateral
flexion
4) Restitution of the buttocks
• The anterior buttocks turns slightly to the mother’s
right side
Mechanism of left sacroanterior position cont.

5. Internal rotation the shoulders

• The shoulders enter the pelvis in the same
oblique diameter as the buttock.
• The anterior shoulder rotates forwards 1/8th
of a circle along the right side of pelvis and
escapes under the symphysis pubis.
Mechanism of left sacroanterior position cont.

6) Internal rotation of the head

• The head enters the pelvis with the sagittal
suture in the transverse diameter of the brim
• The occiput rotates forwards along the left
side and the suboccipital region (nape of the e
neck) pivots on the undersurface of the
symphysis pubis.
 Mechanism of left sacroanterior position cont.

7)External rotation of the body

• The body turns at the same time as the head
rotates internally, so that the back is
uppermost
8)Birth of the head
• The chin, face and sinciput sweep the
perineum and the head is born in a flexed
attitude.
 Management of Labour

Indications for vaginal delivery:

• Foetus neither too big nor too small (1,500 –
3, 700g)
• Well flexed head
• Good capacity of the pelvis (previous delivery
of infant weighing 2.5kg or more or through
pelvimetry
• Frank breech
 Mgt of First Stage of Labour

• The woman is reassured. Condition is

explained to her and she is told that vaginal
delivery may be possible but there is also a
risk of delivery by Caesarean Section

• The woman’s hydration is assessed

 Mgt of First Stage of Labour

• Assess the woman’s emotional state and

coping ability
• Perform abdominal examination
• Give analgesia/sedation if necessary. Epidural
block may be offered as it reduces the urge to
push prematurely
 Mgt of First Stage of Labour
cont.
• Set up infusion (if necessary) or in late first
stage
• Provide emotional support and physical
comfort for example: stay with client and
encourage her
• Clean client’s face and hands with wet cool
towel
• Massage client’s sacral region
 Mgt of First Stage of Labour
cont.
• Put client on partograph (the descent of
presenting part (breech) is not examined in
5th). The station should be used).
• Take blood for grouping and cross matching
• Do vaginal examination when membranes
rupture to exclude cord prolapse help the
woman to assume the position she feels most
comfortable in
 Mgt of Second Stage

• Full dilatation of the cervix should be confirmed by

vaginal examination before the woman starts
pushing
Note : This is because in a footling presentation a
foot may appear at the vulva when the cervix is
not fully dilated, or when the cervix is only
partially dilated, or when legs are extended
especially if the foetus is small the breech may slip
through a cervix which is not completely dilated.
 Mgt of Second Stage

• The head may be trapped by the cervix when

the foetus is partially delivered
• The midwife should inform the obstetrician to
be present for the delivery
• The anaesthetist should also be informed in
case a general anesthesia is needed.
 TYPES OF BREECH DELIVERY

A. Spontaneous breech delivery – the delivery occurs with little

assistance from the doctor or midwife. It is more common
in multigratvidae or in small preterm breech.

B. Assisted breech delivery – the buttocks are born

spontaneously, but some assistance is necessary for
delivery of extended legs or arms and the head

C. Breech extraction – this is a manipulative delivery done by

an obstetrician and is performed to speed delivery in an
emergency situation.
 A. SPONTANEOUS BREECH DELIVERY
Management of Delivery in the District

The midwife should

• Do vaginal examination to confirm full dilatation
• Put the woman in the lithotomy with the
buttocks at the end of the bed when the breech
reaches the pelvic floor (unless the woman
chooses the upright position)
• Drape the woman with sterile towel
• Swab the vulva
 Management of Delivery in the District

• Empty the woman’s bladder

• Ask the woman to push with contractions and
rest in between
• Perform episiotomy when the perineum is
distended
• Await delivery of legs, buttocks, trunk and arms
• Deliver the head by supporting trunk and flexing
head down, if head fails to deliver, REFER.
 Management of Delivery in the Hospital

• When the buttocks are distending the perineum

the woman is put in the lithotomy position
(unless/the woman chooses the upright position)
• Swap the vulva
• Drape the woman
• The woman is then put in the lithotomy position
with the buttocks at the end of the bed (unless
the woman chooses the upright position).
 Management of Delivery in the Hospital

• The bladder is emptied.

• Give episiotomy
• The woman is encouraged to push during
contractions and rest in between
Management of Delivery in the Hospital cont.

• The buttocks are delivered spontaneously

• If the legs are flexed, they come out
(disengage of the vulva)
• The baby is born up to the umbilicus
• A loop of the umbilical cord is pulled down
(this is to avoid traction on the umbilicus. It is
usually done, when there is tension on the
cord).
Management of Delivery in the Hospital cont.

Note: Do not stretch the cord or manipulate it

because it can lead to spasm of the cord vessels.
• If the cord is being squeezed behind the pubic bone,
it should be moved to one side.
• Feel for the elbows (these are, normally on the chest).
• If it is on the chest, the arms will escape with the next
contraction
Note: If the arms are not felt, then they are extended.
 Delivery of the Shoulders

• The shoulders are brought down to the pelvic

floor by the contractions and the weight of the
body.
• They are then rotated into the anteroposterior
diameter of the outlet.
• Wrap a small towel around the baby’s hips
(This keeps the baby warm and help the
Midwife to apply traction)
 Delivery of the Shoulders

• It also help the attendant to have a tight grasp

(grip) of the body)
• Grasp (hold firmly the baby by the iliac crest
with the thumbs held parallel over the
sacrum.
• The baby is then lifted towards the maternal
sacrum in order to free the anterior shoulder
 Delivery of the Shoulders
cont.
• When the anterior should has been freed the
buttocks are lifted towards the mother’s
abdomen to enable the posterior shoulder and
arm to pass over the perineum.
• As the shoulders are born the head enters the
pelvic brim and descends through the pelvis with
the sagittal suture in the transverse diameter
• The back must remain lateral until the sagittal
sature is in the trasverse diameter.
 Delivery of the Shoulders
cont.
• Note: If the back is turned upward too soon,
the anteroposterior diameter of the head
will enter the anterioposterior diameter of
the brim and head may become extended.
The shoulders may then become impacted at
the outlet and the extended head may cause
difficulty.
 Delivery of the head

• When the back has been turned, the baby is allowed to

hang from the vulva without support
NB. Allowing the baby to hang on his own weight for a few
moments help descent and flexion of the head. Thus the
head is brought into the pelvic floor on which the occiput
rotates forwards
• The saggital suture turns into the anteroposterior diameter
of the outlet
• If rotation of the head fails to take place, two fingers should
be placed on the malar bones and the head rotated.
 Delivery of the head

• The baby can be allowed to hang for 1 to 2

minutes
• The neck elongates gradually
• The nape of the neck and the hairline appears
 Delivery of the head
cont.
• NB When the nape of the neck and the hair
line is seen it shows that the head is now
ready to be born.
• Controlled delivery of the head is then done to
avoid any sudden change in intracranial
pressure which result in cerebral haemorrhage.
• Three methods can be used to deliver the head.
 Delivery of the head
cont.
1. Forceps delivery-the obstetrician applies
forceps to the after coming head

2.Burns Marshall method

3.Mauriceau Smellie – Veit manoeuvre,

1. Forceps delivery of the “after coming”
head of breech
 2.Burns Marshall method

• The midwife or the doctor:

• Stands facing away from the mother and with
the left hand, grasp the baby’s ankles from
behind and forefinger between the two

• Keep baby on a stretch with slight traction to

prevent the neck from bending backwards to
cause fracture
 Delivery of the head using Burn’s Marshall
cont.
• The sub-occipital region should pivot (turn
round) under the apex of the pubic arch and
• NOT the neck. This will prevent the spinal
cord from being crushed.
 Delivery of the head using Burn’s Marshall
cont.
• Take up the feet through an arc of 180o (half a
circle)

• The mouth and nose are free at the vulva

 Delivery of the head using Burn’s Marshall
cont.
• The right hand may guard the perineum in
order to prevent sudden escape of the head
• The airway may be cleared by the assistant
• Ask the mother to take regular breaths to
allow the vault of the skull to escape gradually,
taking 2-3 minutes
Burns Marshall method
 3. Mauriceau – Smellie – Veit manouvre

• This is a manouvre to deliver a breech which

involves jaw flexion and shoulder traction.
• It is mainly used when there is delay in
descent of the head because the head is
extended.
• Excessive shoulder traction my cause Erbs
palsy .
 Mauriceau – Smellie – Veit manouvre

• However, it can be used for any breech

delivery.
• The baby is laid astride (leg on each side of )
the right arm with the palm supporting the
chest
 Mauriceau – Smellie – Veit manouvre
cont.
• Insert one or two fingers of the left hand well back
into the mouth to pull the jaw downwards and flex
the head.
• Two fingers of the left hand are hooked over the
shoulders with the middle finger pushing up the
occiput to aid flexion
• Traction is applied to draw the head out of the vagina
• Oxytocic (Uterotonic) drugs are given after the head is
delivered.
Mauriceau – Smellie – Veit manouvre
cont.
Mauriceau – Smellie – Veit manouvre
cont.
 B. ASSISTED BREECH DELIVERY
Delivery of extended legs
• Delay may occur at the outlet because the legs
splint the body/trunk limiting the movement of
the lateral flexion of the spine. The baby can then
be born with legs extended but assistance is
needed.
• When the popliteal fossae appear at the vulva, two
fingers are placed along the length of one thigh
with the fingertips in the fossa. The leg is swept to
the side of the abdomen (Thus the hip is abducted)
 Delivery of extended legs
• The knee is flexed by the pressure on the
undersurface
• As this movement is continued the lower part of
the leg will come out of the vagina
• The same process is repeated in order to deliver
the second leg
• Note: If the knee is pulled forwards from the
abdomen, it can result in severe injury to the
joint
Delivery of extended legs cont.
 ASSISTED BREECH DELIVERY
Delivery of the extended arms

• Diagnosis of the extended arms is made:

• When the elbows are not felt on the chest

after the umbilicus is born.

• The arms can be delivered by using Loveset

manouevre
 Delivery of extended legs cont.
• Loveset monoeve is a combination of rotation
and downward traction.
• It can be used to deliver the arms whatever
position they are in.
• The manouvre depends on the fact that the
posterior shoulder is below the sacral
promontory while the anterior shoulder is
above the symphysis pubis.
 Delivery of the extended arms
Cont.

• The direction of the rotation must always

bring the back uppermost and the arms are
delivered from under the pubic arch.
• When the umbilicus is born, the shoulders are
in the anteroposterior diameter.
• The baby’s thighs are grasped by the iliac
crests with thumbs over the sacrum
 Delivery of the extended arms
Cont.

• Downward traction is applied until the axilla is

visible, at the same time turning it through
half a circle, 180o starting by turning the back
uppermost
• As the shoulder becomes anterior, the friction
of the posterior arm against the pubic bone
sweeps the arm in front of the face.
 Delivery of the extended arms
Cont.

• The movement allows the shoulders to enter the

transverse diameter
• The arm, which is now anterior is delivered.
• The first two fingers of the hand that is on the same
side as the baby’s back are used to splint the humerus
and draw it down over the chest as the elbow is flexed
• The body is now rotated back in the opposite direction
and the second arm delivered in a similar way
Delivery of the extended arms
Cont.
 Delay in the delivery of the head.

• Extended head- The head is probably extended

when the neck and hair line are not visible
when the body has been allowed to hang.
• Extended head can be delivered by forceps or
Mauriceau – Smellie – Veit manoeuvre
• If the head is trapped in an incompletely
dilated cervix, an air channel can be created to
enable the baby to breath before intervention.
 Delay in the delivery of the head.

• This is done by inserting two fingers or a sims

speculum in front of the baby’s face and
holding the vaginal wall away from the nose.
• Moisture is cleared and the airways are
cleared
• Mc Roberts manoevre can be used to help the
release of the fetal head.
 Delay in the delivery of the head.
Cont.
• The woman brings her knees up to the chest
as far as possible
• This manoeuvre will rotate the angle of the
symphysis pubis superiorly and the weight of
the mothers legs to create gentle pressure on
the abdomen, releasing the impaction.
McRobert’s manoevre
 Breech Extraction

• This method of delivery is sometimes used for

delivery of the second twin. However, this
operation carries a lot of risks and should not be
attempted unless;
• There is no cephalopelvic disproportion
• The cervix is fully dilated
• The mother has general or epidural anaesthetic,
and
• A skilled obstetrician is available
 C. BREECH EXTRACTION

• Procedure
• The obstetrician extracts the breech from the
birth canal, manipulating the foetus, in contrast
to the movements of the foetus produced by
uterine contractions when labour is normal

• NOTE: this is usually not done in developing

countries including Ghana.
 Complications of breech presentation

• Impacted breech (labour is obstructed when the

foetus is too large for the size of the pelvis)
• Cord prolapse (due to the ill-fitting presenting part the
cord can slip down)
• Birth injury
• Superficial tissue damage e.g. bruising, oedema and
bruising of the baby’s genital, oedema and
discolouration of foot when the prolapse foot lies in
the vagina or at the vulva for a long time in footling
breech.
 Complications of breech presentation

• Dislocation of shoulder
• Dislocation of the hips
• Fracture of humurus
• Fracture of clavicle
 Complications of breech presentation
cont.
• Fracture of femur
• Erbs palsy caused by the brachial plexus being
damaged by the twisting of the neck.
• Truama to internal organs, especially a
ruptured liver or spleen (due to pressure or
grasping of the abdomen)
 Complications of breech presentation
cont.
• Damage to the adrenals leading to shock
caused by adrenaline release
• Spinal cord damage or fracture of the spine
(caused by bending the body backwards over
the symphysis pubis while delivering the head)
• Intracranial haemorrhage (caused by rapid
delivery of the head which has had no
opportunity to mould or hypoxia
 Complications of breech presentation
cont.
• Foetal Hypoxia (this may be due to cord
prolapse, and cord compression or premature
separation of the placenta).
• Premature separation of the placenta (due to
retraction of the uterus while the head is still
in the vagina causing the placenta to begin to
separate)
• Maternal trauma
 SHOULDER PRESENTATION
(Transverse lie)

• Definition: shoulder presentation is a condition

in which the long axis of the foetus lies across
the long axis of the uterus.
• NB: it is the most dangerous of all the mal
presentation. The lie is more oblique than
transverse
• Incidence: 1:300 deliveries. It is much greater in
multiparae and where there is no antenatal care.
 SHOULDER PRESENTATION
(Transverse lie)

CAUSES (PREDISPOSING)
• Maternal
1.Lax abdomen and uterine muscle
2.Uterine abnormality
- Unterine fibroids
- Placenta praevia
3.Contracted pelvis
4.Polyhydramnios
 SHOULDER PRESENTATION
(Transverse lie)

• Foetal causes
1.Prematurity
2.Multiple pregnancy
3.Macerated foetus (lack of muscle tone causes
the foetus to drop down into the lower pole of
the uterus)
 SHOULDER PRESENTATION
(Transverse lie)

4. Multiple pregnancy
• There may be polyhydramnios but the
presence of more than foetus reduces the
room for manoeuvre even when the amount
of liquor is normal. The second twin usually
adopts this lie after delivery of the first twin.
5.Short cord
 DIAGNOSIS
• Antenatal Period
• Abdominal Examination
1. Inspection
• The fundus is lower than expected for period of gestation,
sometime, being higher on one side than the other
• The uterus appears wider than usual.
2. Palpation
• The mobile head is felt on one side of the abdomen and
the breech at a slightly higher level on the other side.
 DIAGNOSIS CONT
3. Auscultation
• The foetal heart is heard below the umbilicus
but this is not diagnostic

4. Ultrasound: Would be used to confirm the lie

and presentation
 DIAGNOSIS CONT
Diagnosis During Labour
• Abdominal Examination
i. Inspection: As for antenatal diagnosis
• Palpation: This is difficult if the uterus in
contracting strongly and becomes moulded
around the foetus.
• When the membranes rupture, the irregular
outline of the uterus is more marked.
 DIAGNOSIS CONT
Vaginal Examination
• This should be performed only after placenta praevia
has been excluded.
• In early labour, the presenting part may not be felt
because it is high.
• Later, if the membranes are ruptured, (which happens
early because of the ill-fitting part), the ribs and the
shoulder which feels as a soft mass are felt.
• If the shoulder enters the pelvic brim, the arm may
prolapse
 Diagnosis of Prolapse of Arm

1.The elbow feels sharper than the knees

2.The fingers are longer than the toes
3.The fingers are of unequal length
4.The thumbs can be abducted
5.The palm is shorter than the sole
6.No os calcis can be felt
7.The hand is not at right angle to the arm
MECHANISM OF SHOULDER PRESENTATION

Position
• Dorso anterior – The foetal back is in front
• Dorso Posterior – The foetal back in behind

• Mechanism
• There is no mechanism

• Prognosis
• In neglected cases, obstructed labour
• Ruptured uterus and it dangers
 MANAGEMENT OF SHOULDER
PRESENTATION
Antenatal
• All cases must be referred to hospital at the 32nd
week of pregnancy
• Hospital mgt
a. External Cephalic version – This is performed if no
underlying cause is suspected
b.Elective caesarean section near term
c. Decaputation – In neglected cases if the foetus
dies
 Dangers/Complications

• Mother
1. Ruptured Uterus

2. Prolonged labour

3. Obstructed labour due to impacted shoulder

4.Infection
 Dangers/Complications

• Foetal
1.Cord prolapse
2.Prolapse arm: this happens when membranes
rupture and the shoulder is impacted
3.Infection
 UNSTABLE LIE

• Description: This is when after 36 weeks of pregnancy, the lie which

should be stable and longitudinal is found to vary. (Breech, cephalic
transverse or oblique) from one examination to another.
Causes
• Any condition in late pregnancy that increases mobility of the foetus
or prevents the head from entering the pelvic brim.
• 1. Polyhydramnios
• 2. Lax uterine muscles in multigravidae
• 3. Contracted pelvis
• 4. Placenta praevia
• Management
• District: Refer client to hospital.
 Hospital management

• Admission at 37-38 weeks to avoid unsupervised

onset of labour and for essential supervision
throughout labour.
• The obstetrician may undertake any of the following:
• Correction of the abnormal presentation after
ultrasound has been done to exclude placenta praevia
etc.
• Many obstetricians induce labour after 38 weeks
gestation having first ensured that the lie is
longitudinal.
 Hospital management

• A controlled rupture of the membranes is

performed so that the head enters the pelvis.
• Syntocinon infusion is used to stimulate the
contractions
• The midwife should ensure that the woman
has emptied her bowels and bladder, before
the procedure
 Hospital management

• She should palpate the abdomen at frequent

internals to ensure that the lie remains
longitudinal and to assess the descent of the
head.
• Planned caesarean section
 Complications of unstable lie

• Maternal
• 1. Prolonged Labour
• 2. Maternal distress
• 3. Ruptured uterus
• 4. Infection

• Foetal
• 1. Cord prolapse
• 2. Infection
• 3. Stillbirth
 COMPOUND OR COMPLEX PRESENTATION

• This is the term used when the hand or the

foot is felt vaginally alongside the head.
Causes
• Small babies
• Roomy pelvis
• Flat pelvis
 COMPOUND OR COMPLEX PRESENTATION

Management
• First Stage
• Medical aid is sought
• Caesarean section may be performed
• Second Stage
• The midwife should try and hold the hand
back, directing it over the face and allow the
head to be delivered.
 SHOULDER DYSTOCIA

• Shoulder dystocia is a rare complication

occurring after delivery of the foetal head, in
which the shoulders fail to rotate, descend
and deliver. (Bailliere’s Midwives Dictionary).
• The anterior shoulder becomes trapped
behind or on the symphysis pubis whilst the
posterior shoulder may be in the hollow of the
sacrum or above the sacral promontory.
 SHOULDER DYSTOCIA cont.

• Predisposing factors (Risk factors)

• Large baby (foetal macosomia) Birth weight over 4kg
- Post term pregnancy
- High parity
- Maternal age over 35 years
- Maternal obesity (weight over 90kg at delivery)
- Maternal diabetes
- Gestational diabetes
• Note: In diabetic women a previous delivery complicated
by shoulder dystocia increase the risk of recurrence to 9.8%.
 SHOULDER DYSTOCIA cont.

In labour the risk factors are:

• Oxytocin augmentation
• Prolonged labour
• Prolonged second stage of labour
• Operative deliveries
 SHOULDER DYSTOCIA cont.

Warning Signs
1.Initial uncomplicated delivery
2.Failure of the head to advance with crowing or the
head may advance slowly
3.Difficulty in delivering the face and chin (the chin
may have difficulty in sweeping the perineum)
4.When the head is delivered it may look as if it is
trying to return into the vagina .
• This is caused by reverse traction.
 SHOULDER DYSTOCIA cont.

• Diagnosis
• Shoulder dystocia is diagnosed when manoeuvres normally
used by the midwife fail to accomplish delivery.
• Management
• The midwife must
1.Call the doctor (obstetrician)
2.Explain the condition and the maneuvers that will be used to
the mother calmly
3.Call the anaesthetist
4.Call the paediatrician or a person who can do neonatal
resuscitation skillfully
 SHOULDER DYSTOCIA cont.

5. If the shoulder are in the anteroposterior

diameter of the outlet
• Attempt first to deliver them in the normal way
• If the shoulder are in the anteroposterior
diameter of the outlet.
• Attempt first to deliver them in the normal way
• If this fails, ensure that the hand is not alongside
the head anteriorly (This is because this can
prevent delivery of the anterior shoulder)
 SHOULDER DYSTOCIA cont.

• If this is found, the posterior shoulder and the

hand are eased out first by using traction
towards the mother’s abdomen.
6.Non invasive produres can be used. These are;
a. Change in position
• Any change in the maternal position may help
release the foetal shoulder some of the positions
include the McRoberts manoeuvre and the
supra pubic pressure.
 SHOULDER DYSTOCIA cont.

1. The McRoberts manoevre

This includes
• Helping the mother to lie flat and to bring her
knees up to her chest as far as possible
• This manoevre will rotate the angle of the
symphysis pubis superiorly and use the weight of
the mother’s legs to create gentle pressure on
her abdomen, releasing the impaction of the
anterior shoulder.
 SHOULDER DYSTOCIA cont.

2.Suprapubic pressure
• Pressure should be exerted on the side of the
foetal back and towards the foetal chest.
• This manoeuvre may help to adduct the
shoulders and push the anterior shoulder
away from the symphysis pubis.
 SHOULDER DYSTOCIA cont.

Note: Adduct means to draw towards the

centre or the midline
Manipulative produres:
These manipulative procedure include:
i. Position of the mother
ii. Episiotomy
iii. Rubins’s manoevre
 SHOULDER DYSTOCIA cont.

iv.Wood’s manoevre
v. Delivery of the posterior arm
vi. Zavenelli manoevre
vii. Symphsiotomy
 SHOULDER DYSTOCIA cont.

i. Position of the mother

1.The McRoberts position
2.Lithotomy position
3.All fours
ii. Episiotomy
• Episiotomy may be performed to gain access to the foetus without
causing tears to the perineum or vaginal wall.
iii. Rubin’s manoevre
• The midwife identifies the posterior shoulder on vaginal examination
• She pushes the posterior shoulder in the direction of the foetal chest,
thus rotating the anterior shoulder away from the symphysis pubis.
 SHOULDER DYSTOCIA cont.

iv. Wood’s manoevre

• The midwife inserts her hand into the vagina
and identifies the foetal chest
• She then exerts pressure on the posterior
shoulder and this results in rotation of the
posterior shoulder.
 SHOULDER DYSTOCIA cont.

v. Delivery of the posterior arm

• The midwife inserts her hand into the vagina by
using the space created by the hallow of the sacrum.
• Two fingers then splint the humerus of the posterior
arm, flex the elbow, and sweep the forearm over the
chest to deliver the hand.
• If the rest of the delivery is not achieved,
• The second arm is delivered after rotation of the
shoulders using either wood’s or Rubin’s manoeuvre
 SHOULDER DYSTOCIA cont.

vi. Zavanelli manoevre

• This is done if all the maneuvers described
fail.
• It is done by the obstetrician
• The head is returned to where it was before
restitution (pre-restitution position)
 SHOULDER DYSTOCIA cont.

• Pressure is then exerted on the occiput and

the head is returned into the vagina
• Caesarean section is then done immediately
vii. Symphysiotomy- this surgical separation of
the symphysis pubis. It is done to enlarge the
pelvis for delivery e.g CPD and shoulder
dystocia.
Complications of shoulder dystocia
A. Maternal
• Ruptured uterus
• Haemorrhage
• Maternal death

B.Foetal
• Neonatal asphyxia
• Brachial plexus injury resulting in Erb’s palsy (When head and
neck are twisted)
• Neonatal morbidity
• Intrauterine death