MALPOSITIONS

AND
MALPRESENTATIO
NS
OCCIPITOPOSTERI
OR, FACE, BROW,
SHOULDER

OCCIPITO-POSTERIOR
Vertex presentation
Occiput in post. Segment of pelvis overlying
the sacroiliac jt and sacrum
3 positions described:
1. Right occipitoposterior
2. Left occipitopoterior
3. Direct occipitoposterior

AETIOLOGY

SHAPE OF PELVIC INLET- anthropoid or

android pelvis

FETAL FACTORS- marked deflexion1) high pelvic inclination

2) placenta on ant. Wall of uterus
3) back on the right side

UTERINE FACTORS- abnormal uterine

contractions

DIAGNOSIS

ABDOMINAL EXAMINATION
Subumbilical flattening
Back is in one or the other flank so clinically
not felt
Limbs felt anteriorly
Shoulder in flanks
Unengaged or high head at term
Occiput and sinciput at same level
Fetal heart sounds in the flanks and are
frequently indistinct

VAGINAL EXAMINATION

Early In Labour-

Early rupture of membranes

Sagittal suture in right oblique diameter
Post. Fontanelle in right posterior quadrant
and ant. Fontanellae in left anterior quadrant
Both fontanelle easily palpated

Late In Labour

Large caput present obscuring the sutures

Pinna points occiput
Perineum gapes much before head distends it
and premature straining can occur
Difficulty in applying forceps in unrecognized
occipitoposterior

MECHANISM OF LABOUR

ENGANGING DIAMETER
Suboccipitofrontal-10.5cm
Occipitofrontal-11.5cm

COURSE OF LABOUR

Anterior rotation- 90% cases, occiput

rotates anteriorly through 3/8 of circle
and baby born occipitoanterior.
Engagement may be delayed and labour
may be longer because of deflexion.

Posterior Rotation And Face To Pubis Delivery

Head is deflexed.
Engaging diameter is occipitofrontal.
Sinciput rotates anteriorly then occiput rotates
posterioirly
Extreme flexion followed by extreme extension
Perineal tears common
Liberal episiotomy needed
Occipitosacral position and face to pelvis are
more common anthropoid pelvis

Failure Of Rotation

Persistent occipitoposterior is the absence of

rotation and head remains as ROP or LOP
Deep transverse arrest is defined as head
being arrested with sagittal suture in
transverse diameter at the level of ischial
spine, after full dilation of cervix and inspite of
good uterine contractions

Reasons-

Deflexion of the head

Inefficient uterine contraction
Weak pelvic floor preventing anterior rotation
Pendulous abdomen and poor muscle tone
Cephalopelvic disproportion and android
pelvis

MANAGEMENT

Most of the malpositions will rotate

anteriorly and the baby will be born
spontaneously as occiput anterior
Posterior rotation- labour longer
Judicious use of fluids, liberal
episiotomy and analgesia needed
-partogram essential
-oxytocin augmentation

1.

2.

DEEP TRANSVERSE ARREST

Caesarean section-android pelvis,
cephalopelvic disproportions, traumatic
vaginal delivery causing intracranial
haemorrhage
Vacuum extraction- ideal- cup at posterior
fontanelle- promotes flexion, thus decreases
presenting diameter- promotes autorotation
suited for the pelvis- less traumatic, no need
for analgesia

3. Manual rotation- under GA

-right hand grasps the sinciput, displacing it and
there by increasing flexion
Small bitemporal diameter allows more space
for the thumb and finger to have firm grasp
across the temple with middle finger on the
frontal suture
In LOP, left hand used- sinciput rotated and
forceps or vacuum used

4. Forceps Rotation Keilland forceps used

Under GA
In anteroposterior direction and rotation
carried out
Adv- forceps need not be reapplied

PERSISTENT
OCCIPITOPOSTERIOR

Oxytocin augmentation tried

Most cases delivery as occipitoposterior
with face to pelvis, assisted with forceps
or vacuum
Rotation to occipitoanterior can be
attempted
Caesarean section otherwise

If any of the attempt to deliver the baby

vaginally fails.. Immediate CS should be
done
Otherwise, fetus may die and craniotomy by
experienced hands or CS must be done

FACE PRESENTATION

Cephalic presentation where the attitude is

one of complete extension, presenting part is
face and denominator is the chin or mentum
Engaging diameter is submentobregmatic9.4cm
Primary face presentation are present before
onset of labour and are rare
Secondary caused by extension during labour
and is most common

POSITIONS

Left mentoanterior(LMA)
Right mentoanterior(RMA)
Right mentoposterior(RMP)
Left mentoposterior(LMP)
70% are mentoanterior and 30% posterior.

INCIDENCE AND
AETIOLOGY

Incidence- 1 in 500

Maternal Causes
- contracted pelvis
- obliquity of uterus
- multiparity or pendulous abdomen

Fetal Factors

-anencephaly and iniencephaly

-cord around the neck
-tumours of neck like congenital goitre
-spasm of sternocleidomatoid muscle
-dolicocephalic head

DIAGNOSIS

ABDOMINAL EXAMINATION
In mentoanterior, back is felt with difficulty as it
is posterior and limbs anteriorly
Head remains high
Cephalic prominence is the occiput and on the
same side as the back
Groove b/w the head and back is prominent
Fetal heart sounds are transmitted through the
chest and heard well anteriorly in
mentoanterior

VAGINAL EXAMINATION
-conical bag of membranes
- chin, mouth, nose, malar eminences and
supraorbital ridges are felt
-in mentoanterior, chin is in one ant. Quadrant
and forehead in opp post. Quadrant
-done gently and without cream to avoid injury
to eyes

MECHANISM OF LABOUR
MENTOANTERIOR POSITION
1. Engagement
-engaging diameter- submentobregmatic-9.4cm
-biparietal diameter-7cm
This diameter pass only when face low down in
perineum
-when face distending the vulva, head engaged

2. DESCENT WITH INCREASING

EXTENSION
-Resistance encountered by extension
-occiput pushed towards back of fetus, while
chin descends
3. INTERNAL ROTATION
-Rotates anteriorly through 45towards
symphysis
Neck traverse the posterior surface of
symphysis pubis

4. FLEXION
-head born by flexion
-chin pivots under symphysis pubis and the
mouth, nose, orbit, forehead ,vertex and
occiput are born by flexion

5. RESTITUTION AND EXTERNAL ROTATION

-of chin occurs towards the side to which it was
originally directed and the shoulder are born
as in vertex

MENTOPOSTERIOR

-2/3RD cases rotate anteriorly through 3/8th circle

and deliver as mentoanterior
-some in oblique diameter and some rotate
posteriorly into the hollow of sacrum
-neck too short to span in the 12cm of the ant.
Aspect of sacrum
-shoulders get impacted along with head making
delivery impossible
-engaging diameter is sternobregmatic-17cm
-no mechanism of labour

CAUSES OF PROLONGED LABOUR

Face is less effective dilator of cervix

No moulding of face
More chance of rupture of membranes
Long internal rotation in mentoposterior
Internal rotation occurs only late in 2nd stage

COMPLICATIONS

MATERNAL

Prolonged labour
Increased risk of operative delivery
Obstructed labour in persistent
mentoposterior

FETAL

Face after delivery is oedematous

Laryngeal oedema can also occur- baby
watched for 24 hrs
Congenital malformations like anencephaly
Birth asphyxia due to cord prolapse and
prolonged labour

MANAGEMENT

Mentoanterior, forward rotation in

mentoposterior- labour allowed
CPD, anencephaly, other anomalies,
persistent mentoposterior, obstructed
labour- CS DONE
Dead baby- CS or craniotomy

BROW PRESENTATION
Most unfavourable
Attitude is one of partial extension,
presenting part being the area between the
ant. Fontanelle above and glabella and
orbital ridges below and denominator is
forehead or frontum
Presenting diameter is verticomental13.5cm
Transitory presentation- flex or extend

INCIDENCE AND
AETIOLOGY

INCIDENCE-1 in 1000
CAUSE- similar to face presentation and
include any factors that interfers with
flexion of head

DIAGNOSIS

Rarely made before labour

ABDOMINAL EXAMINATION
High mobile head, which feels large from
side to side
Cephalic prominence is the occiput and is on
same side as back and groove between
cephalic prominence and back is less
prominent than in face presentation

VAGINAL EXAMINATION

Membranes felt in early labour

Anterior frontanelle is felt at one end and root
of nose and orbital ridges at other end of
oblique or transverse diameter
Nose and mouth are palpable but not the chin

MECHANISM OF LABOUR

Presenting diameter - verticomental

No mech of labour for persistent brow
presentation
Spontaneous labour only if baby very
small or pelvis large
In persistent brow, verticomental dia is
shortened & the occipitofrontal dia
elongated with marked moulding and
large caput on forehead

COMPLICATIONS
Both maternal and fetal risks are more
MATERNAL
Obstructed labour and rupture uterus
FETAL
Birth asphyxia

MANAGEMENT

ANTEPARTUM
Wait till labour
EARLY LABOUR
If membrane not ruptured wait for correction
After membrane rupture, brow presentation
diagnosed and in persistent brow presentation
CS done
Prologed labour with head high.. Brow
presentation must be suspected

LATE LABOUR
If features of obstructed labour or if fetus
dead- immediate CS done
If baby dead- also craniotomy

SHOULDER PRESENTATION AND

TRANSVERE LIE

Long axes of fetal and maternal ovoid

are approximately at right angles to each
other and shoulder is presenting in the
pelvic inlet.
Denominator- acromion
POSITIONS
Right acromial
Left acromial

DEPENDING UPON DIRECTION OF THE

BACK

Dorsoanterior
Dorsoposterior
Dorsosuperior
Dorsoinferior

INCIDENCE AND
AETIOLOGY

Incidence- 1 in 500
MATERNAL FACTOR
Multiparity
Contracted pelvis
Uterine anomalies like septate,bicornuate
and arcuate uterus
Placenta praevia
Fibroid in the lower segment

FETAL FACTORS

Prematurity
Multiple pregnancy
Polyhydraminos
IUD

DIAGNOSIS

ABDOMINAL EXAMINATION
Transversely stretched
Fundal height less than period of gestation
No Fetal pole at fundus
Ballotable head in one flank & breech in the
other
In dorsoanterior, back is felt a uniform
reistance acros the front of abdomen
In dorsoposterior, limbs are felt anteriorly
Empty pelvic grip

VAGINAL EXAMINATION

Conical bag of membranes with a high

presenting part
Hand/shoulder/elbow may be felt as a
uniform resistance across the front of
abdomen
Shoulder can be identified by ribs running
parallel to each other
Late in labour, shoulder may be wedged in
the pelvis and hand freequently prolapse into
the vagina

Thumb of the prolapsed hand, when

supinated points to head
To side, to which the prolapsed hand
belongs, can be determined by shaking hand
with the fetus. If the right hand is required,
prolapsed hand is the right and viceversa
ULTRASONOGRAPHY
Confirms diagnosis and position
Rules out anomalies
Rules out placenta praevia

MECHANISM OF LABOUR

NO mechanism of labour
Spontaneous version to breech or by
spontaneous rectification to vertex can occur
Rarely if fetus small or dead delivery occurs
by:
Spontaneous expulsion or birth corpora
conduplicata where fetus is expelled doubled
up
Spontaneous evolution where breech and
trunk are expelled followed by head

NEGLECTED SHOULDER PRESENTATION

Due to ill fitting presenting part, membranes
may rupture early and freequently ensues cord
prolapse, once labour commence
A labour pain becomes stronger, the shoulder
forced into the pelvic inlet
Nullipara- uterine inertia
Multipara-bandl ring or pathological retraction
ring-obstructed labour- neglected shoulder
presentation
Mother-exhausted,febrile and urine show ketone
bodies-uterine rupture- death of both mother
and baby

COMPLICATIONS

MATERNAL
Increased chance of caesarean section
Obstructed labour or ruptured uterus
FETAL
Birth asphyxia due to cord prolapse and
in obstructed labour

MANAGEMENT

EXTERNAL CEPHALIC VERION

At term or early in labour if membranes
intact and not contraindicated
More successful in multipara
If successful followed by stabilizing
induction
More success than for breech

CAESAREAN SECTION
Best option
When ECV fails and CI
Transverse inscision
NEGLECTED SHOULDER PRESENTATION
If baby dead-CS or craniotomy

Reference

Shiela B, Text book of Obstetrics.