Fetal Malpresentation

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

1. BREECH (4%)Complete (Flexed) Breech Presentation Footling Breech PresentationFrank (Extended) Breech Presentation

Kneeling Breech Presentation2. VERTEX (95%)

Brow Presentation Face PresentationSincipital Presentation

3. TRANSVERSE (1%)

 Diagnosis of breech presentationThe diagnosis of abnormal fetal presentations is commonly made with a

combination of Leopold’s Maneuver, Vaginal examination, and Ultrasound.

On abdominal palpation the fetal head is found above the mother’s umbilicus as a hard, smooth, rounded mass, which gently ‘ballots’ (can be rocked) between your hands.

Why do you think a mass that ‘ballots’ high up in the abdomen is a sign of breech presentation? 

The baby’s head can ‘rock’ a little bit because of the flexibility of the baby’s neck, so if there is a rounded, ballotable mass above the mother’s umbilicus it is very likely to be the baby’s head. If the baby was ‘bottom-up’ (vertex presentation) the whole of its back will move of you try to rock the fetal parts at the fundus

Once the fetus has engaged and labour has begun, the breech baby’s buttocks can be felt as soft and irregular on vaginal examination. They feel very different to the relatively hard rounded mass of the fetal skull in a vertex presentation. When the fetal membranes rupture, the buttocks and/or feet can be felt more clearly. The baby’s anus may be felt and fresh thick, dark meconium may be seen on your examining finger. If the baby’s legs are extended, you may be able to feel the external genitalia and even tell the sex of the baby before it is born.Fetal heart tone auscultation: Breech Fetal heart best heard above UmbilicusCervical examination

No hard head palpated in Pelvis Fontanels and Sutures not palpable Soft buttocks palpated with hard irregular Sacrum Skin of buttocks is smooth Feet may be presenting part in Pelvis

Types of Malpresentation

A. BREECHBreech presentation means that either the buttocks or the feet are the first body parts that will contact the cervix. Breech presentations occur 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.

Risk Factors: Prematurity; Multiple prior pregnancies; Polyhydramnios or oligohydramnios; Uterine abnormalities; Fetal abnormalities (e.g. Down Syndrome, Hydrocephalus); Macrosomia; Twin Gestation; Breech Presentation in prior pregnancy; Absolute Cephalopelvic Disproportion

Types of Breech Presentation

1. Frank breech The baby's bottom comes first, and the legs are flexed at the hip and extended at the knees (with feet near the ears). 65-70% of breech babies are in the frank breech position.

2. Complete Breech The baby's hips and knees are flexed so that the baby is sitting crosslegged, with feet beside the bottom.

2. Footling Breech One or both feet come first, with the bottom at a higher position. This is rare at term but relatively common with premature fetuses.

4. Kneeling Breech The baby is in a kneeling position, with one or both legs extended at the hips and flexed at the knees. This is extremely rare.

Maternal RisksProlonged 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.

Managementa. If the woman is in early labor and the membranes are intact, attempt External

Cephalic Version. ECV involves the lifting of the fetal bottom with one hand whilst

the fetal head is pushed down with the other, moving the fetus in an anti-

clockwise direction.b. Tocolytics , such as Terbutaline 0.25 mg IM, can be used before ECV to help relax the

uterus.c. If ECV is successful, proceed with normal childbirth. If EVC fails or is not advisable,

deliver by caesarean section.

Attempt external version if: Breech presentation is present at or after 37 weeks (before 37 weeks, a successful version is more likely spontaneously revert back to breech presentation)Vaginal delivery is possibleMembranes 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, HPN, fetal death).

Attempting ECV at term reduces the risk of a non-cephalic birth and caesarean section.Success rates of ECV range between 30-80%. Factors contributing to successful ECV include: multiparity, non-white race, relaxed uterine tone, adequate liquor volume and a station above the pelvic brim.ECV is a safe procedure that has been shown not to increase the risk of intrauterine death within and after 24 hours of the procedure, irrespective of the outcome of ECV.Complications associated with ECV are uncommon but include placental abruption,uterine rupture and fetomaternal haemorrhage.It should only be carried out by appropriately trained practitioners where facilities for continuous fetal monitoring, ultrasound and emergency caesarean delivery are available.

VAGINAL BREECH DELIVERYVaginal delivery of a breech presentation requires great skill if the fetus is not to be damaged.

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 - fetus is not too large- no previous caesarean section for cephalopelvic disproportion- flexed head.

Induction of labour  may be considered (given favourable circumstances) but augmentation of labour is not recommended.Continuous fetal monitoring should be offered to all women with a breech presentation in labour. Fetal blood sampling from the buttocks is not advised.Epidural anaesthetic avoids pushing before full dilation and permits emergency operative intervention. However Royal College of Obstetricians and Gynaecologists (RCOG) guidelines suggest that it should not be routinely advised and that women should have a choice of analgesia.RCOG guidelines suggest delivery in the lithotomy position, as experience is greatest with this.The maxim is "hands off the breech". Avoid beginning extraction of the fetus prior to complete descent - the cervix must be fully dilated and effaced with the infant's umbilicus at the vaginal introitus.Legs deliver and a towel is wrapped around the legs and pelvis.As the scapulae are delivered, the fetus' back rotates laterally. Avoid traction. Delayed delivery of the arms should be managed by sweeping them across the baby's face and downwards or by the Lovset manoeuvre (rotating the baby to aid delivery of the arms).Once the shoulders are delivered, the head rotates typically to the fetal chin posteriorly. Controlled, slow delivery of the after-coming head is essential. The fetal head should be maintained in a flexed position to allow delivery of its smallest diameter. This can be accomplished by:

o Mauriceau-Smellie-Veit manoeuvre (with fetus resting on hand and forearm, the operator's index and middle fingers lift up the fetal maxillary prominences and an assistant applies suprapubic pressure).

o The Burns-Marshall method (feet are grasped and with gentle traction swept in a low arc over the maternal abdomen).

o Forceps delivery.Avoid extreme elevation of the body, as this may cause hyperextension of the cervical spine.If conservative methods fail to deliver the after-coming head, symphysiotomy or rapid caesarean section is advised.

Complications (Vaginal delivery)

Premature rupture of membranes  and premature labour. Cord prolapse  (higher risk with footling or complete breech). Fetal head entrapment. Overly rapid descent of after-coming head leading to rapid

compression/decompression causing intracranial haemorrhage. Cervical spine injuries associated with hyperextension. Delay in delivery, leading to asphyxia due to cord compression and placental

separation. Traumatic injuries including fractures of the humerus, femur or clavicle, brachial

plexus injury (Erb-Duchenne palsy).

Prognosis (Vaginal delivery) Perinatal mortality is increased with breech presentation by a factor of between 2 and

4 regardless of the mode of delivery. Deaths are most often associated with malformations, prematurity and intrauterine fetal demise.

Breech presentation is associated with an increased risk of abnormalities, especially developmental dysplasia of the hip.

CESAREAN SECTION for breech presentation. Planned caesarean section reduces the risk of perinatal death and early neonatal morbidity in breech babies at term, compared to those born by planned vaginal delivery.Planned caesarean section carries a small increased risk of serious intrapartum complications for the mother compared to planned vaginal delivery but does not carry any additional risk to their long-term health outside of pregnancy.

A cesarean section is safer than vaginal breech delivery and recommended in cases of: Double footling breechSmall or malformed pelvisVery large fetusPrevious cesarean section for cephalopelvic disproportionHyperextended or deflexed head.

B. TRANSVERSEIn 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.Shoulder Presentation

Occurs when fetus is transverse with back down Shoulder sits over pelvic inlet

Do not attempt to turn a sideways lying baby. Unless a trained physician or midwife can turn the baby ‘head down’, it must be delivered by caesarean surgery.

Causes of shoulder presentationCauses of shoulder presentation could be maternal or fetal factors.

Maternal factors include: Lax abdominal and uterine muscles: most often after several previous pregnancies; Uterine abnormality; Contracted (abnormally narrow) pelvis.Fetal factors include: Preterm labour; Multiple pregnancy; Polyhydramnios; Placenta previa.

Diagnosis of shoulder presentationOn abdominal palpation, the uterus appears broader and the height of the fundus is

less than expected for the period of gestation, because the fundus is not occupied by either the baby’s head or buttocks. You can usually feel the head on one side of the mother’s abdomen. On vaginal examination, in early labour, the presenting part may not be felt, but when the labour is well progressed, you may feel the baby’s ribs. When the shoulder enters the pelvic brim, the baby’s arm may prolapse and become visible outside the vagina.

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 this “wedged” position.

Complications of shoulder presentationComplications include: Cord prolapsed; Trauma to a prolapsed arm; Obstructed labour and ruptured uterus; Fetal hypoxia and death.

Remember that a shoulder presentation means the baby cannot be born through the vagina; if you detect it in a woman who is already in labour, refer her urgently to a higher health facility.

In all cases of malpresentation or malposition, do not attempt to turn the baby with your hands! Only a specially trained doctor or midwife should attempt this. Refer the mother so she and her baby can get emergency obstetric care.

C. SINCIPUTThe sinciput presentation occurs when the larger diameter of the fetal head is presented. Labor progress is slowed with slower descent of the fetal head.

D. FACEThe face presentation is caused by hyper-extension of the fetal head so that neither the occiput nor the sinciput is palpable on vaginal examination.   FacePresentationIncidence is about 1in 500births

Causes:- In many cases there is no obvious cause

Anencephaly (10%)prematurity (25%) multiple pregnancy. loops of cord around the neck anda swelling in the neck such as goitre or cystic hygroma

Diagnosis: On abdominal examination there is depression between the anterior shoulder and the head prominence . -The fetal heart sounds are heard best on the same side as the limbs . -Vaginally the mouth ,nose and orbits can be felt.

Diagnosis of face presentationFace presentation may not be easily detected by abdominal palpation, especially if the chin is in the posterior position. On abdominal examination, you may feel irregular shapes, formed because the fetal spine is curved in an ‘S’ shape.

However, on vaginal examination, you can detect face presentation because:

The presenting part will be high, soft and irregular.

When the cervix is sufficiently dilated, you may be able to feel parts of the face, such as the orbital ridges above the eyes, the nose or mouth, gums, or bony chin.

If the membranes are ruptured, the baby may suck your examining finger!

But as labour progresses, the baby’s face becomes oedematous (swollen with fluid), making it more difficult to distinguish from the soft shape you will feel in a breech presentation.

ManagementIn the chin-anterior position prolonged labor is common. Descent and delivery of the head by flexion may occur.In the chin-posterior position, however, the fully extended head is blocked by the sacrum. This prevents descent and labor is arrested.

ManagementChin-Anterior PositionIf the cervix is fully dilated:

Allow to proceed with normal childbirth;

If there is slow progress and no sign of obstruction, augment labor with oxytocin;

If descent is unsatisfactory, deliver by forceps.

If the cervix is not fully dilated and there are no signs of obstruction:

augment labor with oxytocin.

Chin-Posterior Position If the cervix is fully dilated:

Deliver by caesarean section.

If the cervix is not fully dilated Monitor descent, rotation

and progress. If there are signs of obstruction, deliver by caesarean section.

*Do not perform vacuum extraction for face presentation.

Complications of face presentationComplications for the fetus include: Obstructed labour and ruptured uterus Cord prolapse Facial bruising Cerebral haemorrhage (bleeding inside the fetal skull).

F. BROWThe brow presentation is caused by partial extension of the fetal head so that the occiput is higher than the sinciput. Incidence about 1:1000 births.

Causes are the same like face presentation .

Diagnosis:- On P.V the supra –orbital ridges and anterior fontanelle are palpable but not the nose ,mouth or chin.

On abdominal examination, the head is high in the mother’s abdomen, appears unduly large and does not descend into the pelvis, despite good uterine contractions. On vaginal examination, the presenting part is high and may be difficult to reach. You may be able to feel the root of the nose, eyes, but not the mouth, tip of the nose or chin. You may also feel the anterior fontanel, but a large caput (swelling) towards the front of the fetal skull may mask this landmark if the woman has been in labour for some hours.

MGT: If the fetus is alive or dead, deliver by caesarean section. *Do not deliver brow presentation by vacuum extraction, outlet forceps or symphysiotomy.

Which are you more likely to encounter — face or brow presentations?Face presentation, which occurs in 1 in 500 full term labours. Brow presentation is

more rare, at 1 in 1,000 full term labours.

G. COMPOUND PRESENTATIONOne or more limbs present with the head or the breech . most commonly a hand with the vertex . A fetal position during delivery in which there are multiple fetal body parts that descends down the birth canal along with the main presenting part. Usually, this includes usually an extremity.The commonest cause is prematurity , others are contracted pelvis , pelvic tumour , poly hydramnios and dead fetus. -The main complcation is prolapse of the cord 

Signs1. Digital cervical exam

1. Hand palpated beside presenting fetal head

Differential Diagnosis2. Fetal foot beside head

ManagementExpectant management

1. Vaginal Delivery usually occursConsider repositioning if descent arrested

a. Elevate fetal handb. Bring head downward

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 Diagnosis with Interventions1. Anxiety

Provide client and family teaching,Be available to client for listening and talkingProvide client support and encouragement.Encourage client to acknowledge and express feelings.Encourage breathing exercises to relieve anxiety.

2. 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.Explain procedures within level of client’s ability to understand and handle.

3. Risk for Injury

Observe closely for abnormal labor patterns.Monitor fetal heart beat and contractions continuouslyBe 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.

4. Risk for infectionStress proper hand washing techniques 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.

Catanduanes State UniversityCOLLEGE OF HEALTH SCIENCES

Department of NursingVirac, Catanduanes

FETAL

MALPRESENTATION

May Jade R. BorjalBSN 4A/Grp3

Prof. Sarah Gonzales, RN, MANClinical Instructor