mafi

1. Managing Malposition and
Malpresentations During Labour
and Delivery

2. Cont…
Definitions
• Malpresentation:- A presentation other than
vertex. Eg. Shoulder face brow and breech.
• Malposition:- This is the malposition of the
normal vertex presentation that when the
occiput occupies the posterior area of the
pelvis (Right or left sacroiliac joint).

4. Cont…
General causes of malpresnetation and
malposition.
• Increased ratio of fluid to fetus.
Eg. - Polyhydramnious Prematurity
• Something preventing the engagement of the
head in to the pelvis.
Eg. - CPD , Placenta praevia
• Abnormal shape of uterus and pelvis
• Laxity of uterine muscles (GMP)
• Multiple pregnancies.

5. Cont…
NB. Malpresentaition and mal position have ill-fitting
presenting part. An ill-fitting presenting part associated
with
• Slow erratic short lived contraction
• Early rupture of membrane with risk of cord prolapsed
• Pause in labour after rupture of membrane leading to
in coordinate and excessive painful labour.
• Premature labour
• Prolonged and obstructed labour
• Rupture of uterus
• PPH
• Fetal and maternal distress
• Increase fetal and maternal mortality and morbidity.

6. Cont…
A. Malpositions
• 1. Occipito Posterior position (OPP)
• Defn - This is when the occiput lies in the
posterior segment of the pelvis. ( Right or left
sacroiliac joints)

7. Cont…
• It is a malposition of vertex presentation.
• OPP occur in approximately 10% of labors.
• A persistent OPP results from a failure of
internal rotation prior to delivery this occurs in
5% of deliveries.
• It is the commonest cause of high head (non –
engagement) in primigravida mother during
the later weeks of pregnancy.
• As a consequence of OPP the fetal head is
deflexed and larger diameters of the fetal skull
present (occipito frontal 11.5 cm)

8. Causes Cont…
The direct cause is often unknown but it may be
associated with
1. An abnormally shaped pelvis.
• In an android pelvis the fore pelvis is narrow and the
occiput tends to occupy the roomiest hind pelvis.
• The anthropoid (oval) pelvis with its narrow transverse
diameter results a failure of internal rotation of the
head.
2. Multiparity
• Lax uterine and abdominal muscles allow more room
so there is risk of both malposition and
malpresentaiton.
• 3. Placenta praevia
• 4. Multiple pregnancy
• 5. Premature baby

9. Cont…
Diagnosis of OPP
A. Abdominal examination.
1. On inspection
• There is a saucer – shaped depression at or just
below the umbilicus. This dip is created by the “
dip” between the head and the lower limbs of
the fetus.
• The high unengaged head with the depression
above it look like a full bladder which is a
deflexed head.

10. Cont…
2. on palpation
• The head is high and feels unduly large.
• The back is difficult to palpate as it is well out
to the maternal side sometimes almost
adjacent to the maternal spine.
• Limbs are felt on both sides of the midline
• Occiput and sinciput are felt on the same
level.

11. Cont…
3. on auscultation
• The fetal back is not well flexed so the chest is
thrust forward therefore the fetal heart can be
heard in the midline.

12. Cont…
During labour
1. The woman may complain of continuous and
severe backache worsening with contraction.
2. Due to an ill-fitting of the presenting part on
the cervix the membranes tend to rupture
early and contraction may be in coordinate.
3. Descent of the head can be slow even with
good contraction.
4. The woman may have a strong desire to push
early because the occiput is pressing on the
rectum

13. Cont…
5. On vaginal examination.
– The finding will depend up on the degree of
flexion of the head.
– Locating anterior fontanelle anteriorlly and
posterior fontanel posteriorlly confirms the
diagnosis of OPP.

14. Cont…
Management of OPP in first stage of labour
• Labour in OPP can be long and painful the
woman may experience severe and
unremitting backache.
• Also the deflexed head does not fit well on to
the cervix and therefore does not produce
optimum stimulation for uterine contraction.

15. Cont…
1. Warm bath if possible
2. Back rub (massaging)
3. Encourage to remain mobile
4. Allow to adapt what ever position that she feels
comfortable.
5. Adequate antipain
6. Prevent dehydration
7. Keep accurate observation
8. Reduce vaginal examination to the minimum.
9. Alleviate fear and stress

16. Cont…
10 . Estimate the progress of labour by descent,
flexion and dilatation of cervix.
11. The woman may experience a strong urge to
push long before the cervix is fully dilated at
this time the cervix become edematous so
that show how to relax and breath in between
contraction.

17. Cont…
Mechanism of long rotation (OPP)
• The lie is longitudinal
• The attitude of the head is deflexed
• The presentation is vertex
• The position is ROP
• The denominator is the occiput
• The engaging diameter SOB (9.5 cm) which is
changed from OF (11.5 cm)

18. Cont…
A. Flexion - descent takes place with increasing
flexion. The occiput becomes the leading part.
B. Internal rotation of the head – The occiput
reaches the pelvic floor first and rotates
forwards 3/8 of the circle (1350) along the
right side of the pelvis.
C. Crowning – The occiput escapes under the
S.pubis and the head is crowned.
D. Extension – The sinciput, face, and chin
sweep the perineum and the head is born by a
movement of extension.

19. Cont…
E. Restitution – Takes place and the occiput turns
1/8 of a circle to the right
F. Internal rotation of the shoulder – The shoulders
enter the pelvis in the right oblique diameter, the
anterior shoulder reaches the pelvic floor first
and rotates forwards 1/8 circle to lie under syp.
G. External rotation of the head – at the same time
the occiput turns a further 1/8th of the circle to
the right.
H. Lateral flexion – The anterior shoulder escapes
under the syp the posterior shoulder sweeps the
perineum and the body is born movement of
lateral flexion.

20. Cont…
The outcomes of OPP (The probable course of
labour)
There are three possible out comes
1. Long rotation to occipito anterior
• This is the commonest out come – 65 – 90%
• With good uterine contractions producing
flexion and descent of the head and rotates
1350 for wards (3/8th of the circle)
• The engaging diameter of the head in long
rotation is SOB (9.5 cm) which is changed from
OF (11.5 cm) due to good uterine contraction..

21. Cont…
2. Short internal rotation
• Also known as persistent occipito posterior, or
face to pubis or unreduced occipito posterior
• It happens in 20% of cases
• The engaging diameter is occipito frontal (11.5
cm)
• Indicates that the occiput fails to rotate fore
wards instead it rotates 1/8 of the circle (450) to
the opposite of long rotation.
• In other words instead of the occiput the sinciput
reaches the pelvic floor first and rotates forwards.
Then the occiput goes in to the hollow of the
sacrum. The baby is born facing the pubic bone
(face to pubis).

22. Cont…
Cause:- Failure of flexion. That is
• The head descends with out increased flexion
and the bi partial diameter of the head (9.5
cm) get caught in the sacrocotyloid (9 cm)
diameter of the pelvis and the sinciput
becomes the leading part.
• It reaches the pelvic floor first and rotates
forwards and then this makes the occiput to
rotates 1/8 (450) of the circle to the opposite
direction of the long rotation bringing the face
under symphysis pubis.

23. Cont…
3. Deep transverse arrest (Incomplete rotation)
• It happens in 15% of cases
• The head descends with moderately flexed
• The engaging diameter is Suboccipito frontal
(10 cm)

24. Cont…
• Cause:- Moderately flexed head. That is the
occiput descends and reaches pelvic floor first
and tries to rotate for ward but gets caught at
the bispinous diameter in the ischial spines
and can not rotate any further and this is
know as deep transverse arrest.
• Arrest may be due to weak uterine
contraction, a straight sacrum or a narrowed
out let

25. Cont…
Management of OPP in second stage of labour
• A. Long rotation
• Rotation usually occur in 2nd stage
• Delivery is normal as occipito anterior position
• If delay is occur by forceps or vacuum

26. Cont…
B. Face to pubis
Diagnosis
• Delay in second stage of labour
• Vaginal examination reveals that Anterior
fontanelle under symphysis pubis it is a
diagnostic.
• Sagittal suture in the anterior posterior diameter
• There is an upward Moulding (sugar loaf
Moulding)
• Excessive bulging of the perineum and gaping of
the anus are evident.

27. Cont…
• In face to pubis the delivery is by further
flexion that is = holding the sinciput back
under the symphysis pubis to allow the
occiput to escape over the perineum and this
is followed by extension of head so that the
forehead, eyes, nose, mouth and chin are
successively born under SYP.(First by flexion
then extension)
• An episiotomy is usually necessary to facilitate
delivery and avoid serious perineal tear.

28. Cont…
C. Deep transverse arrest
Diagnosis
• Prolonged 2nd stage with no advices of descent in
spite of good uterine contractions
• Excessive caput
• Sagittal suture felt in transverse diameter with
the fontanelle on either sides as the level of
ischial spines
• Delivery management if possible it is corrected
with use of Kiellands rotation forceps or manually
pushing the head above the spines and
completing the rotation manually.
• Rarely a LSCS may be necessary

29. Cont…
Complication of OPP
• Prolonged labour
• Hypotonic uterine action
• PROM
• Prolapse of the cord
• PPH
• Cerebral hemorrhage
• Perineal laceration

30. B. Malpresnetations
1. Face presentation
• Defn :- When the attitude of the head is one
of complete extension the occiput of the fetus
will be in contact with its spine and the face
will present.

32. Cont…
• The engaging diameter is sub mento
bregmatic 9.5 cm
• The denominator is mentum or chin
• It occurs 1 in 500 deliveries
• The majority develop during labour from
vertex presentation with the occiput posterior
this is termed as secondary face presentation.
• Less commonly the face presents before
labour this is termed primary face
presentation.

33. Cont…
• There are eight positions in face presentation
this are
1. Right mentoanterior (RMA)
• This is when the mentum points to the right
iliopectineal eminence.
2. Left mento anterior. (LMA)
• When the mentum points to the left iliopectineal
eminence
3. Right mento lateral (RML)
• When the mentum points mid way between the
right iliopectineal eminence and the right
sacroiliac joints.

34. Cont…
4. Left mento lateral (LML)
• When the mentum points mid way between
the left iliopectineal eminence and the left
sacro iliac joints.
5. Right mento posterior (RMP)
• When the mentum points to the right sacro
iliac joints
6. Left mento posterior (LMP)
• When the mentum points to the left sacro
iliac joints.

35. Cont…
7 Direct mento anterior (DMA)
• When the mentum points directly to the
symphysis pubis
8. Direct mento posterior (DMP)
• When the mentum points directly to the
promontory of the sacrum

36. Cont…
Causes
1. Anterior obliquity of the uterus
• The uterus of a multiparous woman with slack
abdominal muscles and a pendulous abdomen
will lean for ward and alter the direction of the
uterine axis.
• This causes the fetal buttocks to lean forwards
and the force of the contractions to be directed in
a line towards the chin rather than the occiput
resulting in extension of the head.

37. Cont…
2. Abnormal pelvis
• In this 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 a face presentation
develops.
3. Polyhydramnious
If the vertex is presenting and the membranes rupture
spontaneously the resulting gush of fluid may cause the
head to extend as it sinks in to the lower uterine segment.
4. Congenital abnormality
• Anencephaly can be a fetal cause of a face presentation.
Because the vertex is absent the face is thrust forward and
presents.

38. Cont…
Diagnosis
A. On abdominal examination
• Inspection:- irregular abdomen the shape of
the fetal spine is that of an S shape.
• Palpation – Prominent occiput is felt on supra
pubic area and a deep groove is felt between
fetal head and back.
• Auscultation – The fetal heart is heard clearly
at midline.

39. Cont…
B. On vaginal examination
• Presenting part feels soft, high and irregular it
may be defined orbital ridges mouth, gums
and mentum. Sometimes there is sucking
reflex.
• Feeling of gums and sucking reflex are
diagnostic for face presentation.
• NB - As labour progresses the face becomes
edematous making it more difficult to
distinguish from a breech presentation.

40. Cont..
Mechanism of a left mento anterior position
• The lie is longitudinal
• The attitude is one of extension of head
• The presentation of face
• The position is LMA
• The denominator is the mentum

41. Cont…
A. Extension – Descent takes place with increasing
extension. The mentum becomes a leading part.
B. Internal rotation of the head
• Occurs when the chin reaches the pelvic floor and
rotates forwards 1/8 of the circle. The chin
escapes under the SYP.
C. Flexion – Takes place and the sinciput, vertex and
occiput sweep the perineum the head is born.

42. Cont…
D. Restitution:- Occurs when the chin turns 1/8
of a circle to the woman’s left.
E. Internal rotation of the shoulder.
F. External rotation of the head
G. Lateral flexion
• The baby born by a lateral flexion of the body

43. Cont…
NB:- The mechanism of face is the same as in
vertex presentation except that.
• Instead of an increase in flexion it is an
increase in extension.
• the chin instead of the occiput rotates
• The head is born by extension until the chin is
delivered and then the head is delivered by
flexion.
• The engaging diameter is SMB.

44. Cont…
Out comes of face presentation
1. Prolonged labour
• Labour is often prolonged because the face is an
ill fitting presenting part and does not there fore
stimulate effective uterine contraction
• In addition the facial bones do not mould in order
to reduce the engaging diameter.
• Mentoanterior positions.
• With good uterine contractions, descent and
rotation of the head occurs and labour progresses
to a spontaneous delivery.

45. Cont…
2. Mento posterior positions
• If the head is completely extended, so that the
mentum reaches the pelvic floor first and the
contraction are effective the mentum will
rotate forwards and the position become
anterior.
3. Persistent mento posterior position
• In this case the head is incompletely extended
and the sinciput reaches the pelvic floor first
and rotates forwards 1/8 of the circle which
brings the chin in to the hollow of the sacrum.

46. • There is no further mechanism
• The face becomes impacted because both
head and chest accommodated in the pelvis.
• This can not be born normally so caesarean
section will be necessary

47. Cont…
5. Reversal of face presentation.
• A face presentation in a PMPP may in some
cases be manipulated to an occipito anterior
position using bimanual pressure.

48. Cont…
Management in labour
A. If the chin is anterior let labour continue.
• If transverse watch that rotates to anterior.
And then when the face distends the
perineum perform an episiotomy then hold
back the sinciput and allow the chin to be
born. Now when the chin is born flex the head
and allow the occiput to be born (First
extension then flexion).

49. Cont…
B. If the head does not descend in the second
stage with mento anterior position inform to
doctor he may apply forceps.
C. If the head is impacted this may be PMPP so
that you may do reversal of face presentation
to occipito anterior position manually.
If this is impossible inform to doctor because a
caesarean section will be necessary.

50. Complications of face presentation
1. Obstructed labour – due to PMPP
2. Cord prolapse – due to an ill – fitting
presenting part
3. Facial bruising
– The baby’s face is always bruised and swollen at
birth with edematous eyelids and lips.
– The midwife must reassure the parents that the
edema will disappear with in 1 or 2 days.

51. 4. Cerebral hemorrhage
• The lack of Moulding of the facial bones can
lead to intracranial hemorrhage caused by
excessive compression.
5. Maternal trauma
• Extensive perineal laceration may occur at
delivery due to the large SMV (11.5) diameter
distending the vagina and perineum.
6. Injury to the eye – always be careful not to
damage the babies eyes with fingers or
antiseptic lotion.

52. 2. Brow presentation
Defn - Is when the sinciput or the area between
the orbital ridged and the anterior fontanel
presents in the lower pole of the uterus.
• Attitude – midway between flexion and
extension (partially extended)
• Denominator – sinciput
• Engaging diameter – mento vertical (13.5 cm)
• It occurs 1:1000 deliveries

53. Causes
• Lax uterus
• Multiple pregnancy
• Hydramnios
• Abnormal shape of pelvis
• Due to extension of vertex presentation

54. Diagnosis of brow
• Brow presentation is not usually detected before
the onset of labour
• On abdominal palpation
• The head is high appears unduly large and does
not descend into the pelvis despite good uterine
contractions.
• On vaginal examination
– The presenting part is high it is difficult to reach the
presenting part it is above the brim and will not enter
it.
– A smooth hairless area is felt with part of the bregma
at one side
– The orbital ridges may be felt (diagnostic)

55. Management of brow presentation
• If brow presentation is diagnosed early in labour
in rare case it may convert to a face presentation
by becoming fully extended or it may flex to a
vertex presentation.
• Brow presentation undiscovered and untreated
will lead to obstructed labour. The engaging
diameter is too big to enter the average pelvis so
delivery will not takes place 13.5 cm of head can
not enter 13 cm of pelvis unless the head is
premature.
• Caesarean section is the management for a live
baby
• Craniotomy if baby is dead.

56. Complications
• Obstructed labour
• Rupture of the uterus
• Injury to the eye of the fetus
• Intera cranial hemorrhage

57. 3. Breech presentation
• Defn When the fetus lies with it’s buttocks in
the lower pole of the uterus.
• Lie is longitudinal
• The presenting diameter is bitrochantric (10
cm)
• The denominator is sacrum
• In mid trimester the frequency is much higher
because the greater proportion of amniotic
fluid facilitates free movement of the fetus.
• It occurs in 3% pregnancies at term.

58. Types of breech presentation
1. Frank breech (Breech with extended legs)
• The most common types of breech (70%)
• The breech presents with the thighs (hips)
flexed and legs extended on the abdomen
• It is particularly common in primigravida
whose good uterine muscle tone
• inhibits flexion of the legs and free turning of
the fetus.

59. 2. Complete breech (Breech with flexed legs)
• The fetal attitude is one of complete flexion
hips and knees both flexed and the feet
tucked in beside the buttocks. The presenting
part therefore bulky and consists of buttocks
the external genitalia, and both feets.
3. Footling breech
• This is rare one or both feet present because
neither hips nor knees are fully flexed. The
feet are lower than the buttocks which
distinguishes it from the complete breech.

60. 4. Knee presentation
• This is very rare only or both hips are
extended with the knees flexed

61. Positions for a breech presentation
1. Right sacro anterior (RSA)
• This is when the sacrum points to the right
iliopectineal eminence.
2. Left sacro anterior (LSA)
• When the sacrum points to the left iliopectineal
eminence.
3. Right sacrolateral (RSL)
• When the sacrum points mid way between the
right iliopectineal eminence and the right
sacroiliac joints.

62. 4. Left sacro lateral (LSL)
• When the sacrum points mid way between the left
iliopectineal eminence and the left sacroiliac joints.
5. Right sacroposterior (RSP)
• When the sacrum points to the right sacroiliac joints
6. Left sacro posterior (LSP)
• When the sacrum points to the left sacroiliac joints
7. Direct sacro anterior (DSA)
• When the sacrum points directly to the symphysis
pubis
8. Direct sacro posterior (DSP)
• when the sacrum points directly to the promontory of
the sacrum

63. Causes
• Often no cause is identified but the following
circumstances favors breech presentation.
• Defluxion attitudes of the fetus are the main
causes in late pregnancy and accounts for the
greater number of extended legs.

64. 3. Extended legs
• Spontaneous cephalic version may be inhibited if
the fetus lies with the legs extended “Splinting”
the back
4. Too much room or too little room.
• Here the fetus is either held tightly and can not
move easily or has so much room to move that
there is a significant risk of mal presentation such
as
– Primigravida – tight abdominal muscle
– Multiparas – lax muscles
– Polyhydramnious
– Pre – term labour
– Oligohydraminous

65. Cont…
4. Abnormality
• Here abnormality of either the fetus or the uterus
can result in a mal presentation such as
– Hydrocephaly (big fetal head accommodate more in
the fundus)
– Septum or fibroid in the uterus
5. Law of accommodation. Such as
– Placenta praevia
– Multiple pregnancy
• Here if a placenta is filling the lower segment or
another fetus is present the fetus will have to
occupy alternative space with in the uterus.

66. Cont…
Diagnosis
1. Palpation
A. On pelvic palpation on head can be detected.
• The pelvic area is occupied by an irregular soft
mass
B. Lie is longitudinal
C. The fundus contains a firm smooth, rounded
mass which ballots between the examining hands
2. Auscultation
• In most causes the fetal heart is heard with
greater clarity above the umbilicus except when a
breech with extended legs engages in the pelvis.

67. Cont…
3. Vaginal examination
A. The breech is felt high, soft, irregular in
shape (and not smooth and round with
palpable sutures as in the head)
B. During labour when membranes are
ruptured the anal sphincter will grip the
examining finger in male fetus we may feels
scrotum.
• Meconium on the examining finger is
diagnostic for breech presentation or
meconium stained amniotic fluid.

68. Cont…
4. X – ray or ultrasound
• May confirm diagnosis.
5. Symptoms
• Frequently the pregnant woman whose fetus
presents by the breech complains of
Cont…
discomfort under the ribs especially when the
fetus moves. This is due to pressure of the
fetal head on the ribs.

69. Cont…
Mechanism of breech delivery (LSA)
• The lie is longitudinal
• The attitude is one of complete flexion
• The presentation is breech
• The position is left sacroanterior
• The denominator is the sacrum
• The presenting part is the anterior (left) buttock
• Engaging diameter – bitrochantric (10 cm)
• The sacrum points to the left iliopectineal
eminence

70. Cont…
1. Compaction
• Descent takes place with increasing
compaction owing to increased flexion of the
limbs
2. Internal rotation of the buttocks
• The anterior buttock reaches the pelvic floor
first and rotates for wards 1/8 of the circle
along the right side of the pelvis to lie
underneath the symphysis pubis. The
bitrochanteric diameter is now in the
anteroposterior diameter of the out let.

71. Cont…
3. Lateral flexion of the body
• The anterior buttock escapes under the symphysis
pubis the posterior buttock sweeps the perineum and
the buttocks are born by a movement of lateral flexion.
4. Restitution of the buttocks
• The anterior buttock turns slightly to the mother’s right
side
5. Internal rotation of the shoulders
• The shoulders enter the pelvis in the same oblique
diameter as the buttocks the left oblique. The anterior
shoulder rotates forwards 1/8 of the circle. A long the
symphysis pubis the posterior shoulder sweeps the
perineum and the shoulders are born

72. 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 a long the left side
and the suboccipital region (the nape of the neck)
impinges on the undersurface of the symphysis
pubis.
7. External rotation of the body
• At the same time the body turns, 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

73. Cont…
Management of uncomplicated breech
presentation in labour
• NB - Before conducting breech presentation
always be sure full dilatation of the cervix
because may be the presenting part escape
out with undilated cervix and then the head
may be delayed and held up at an un dilated
cervix.
• If vaginal delivery is selected the chance of
successes is 50%.

74. Cont…
A. Management of breech presentation in first stage of
labour
• The basic care is the same as normal labour
• The chance of rupture of membrane is high in
complete breech due to an ill-fitting the presenting
part. So that the risk of cord prolapse should be
excluded by vaginal examination.
• If the membrane is not rupture spontaneously at an
early stage it is safer to leave them intact until labour is
well established and the breech at the level of ischial
spines.
• Meconium – stained liquor is some times found due to
compression of the fetal abdomen and is not always a
sign of fetal distress.

75. Cont…
B. Management of breech presentation in second stage of
labour
• Full dilatation of cervix should always be confirmed by
vaginal examination before the woman commences active
pushing.
• Active pushing is commenced when the buttocks distending
the vulva.
Types of breech delivery
A. Spontaneous breech delivery
• When delivery occurs with little assistance
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 carried out usually by an
obstetrician.

76. Cont…
C. Footling breech

77. Cont…
Steps of delivery
1. Delivery of the buttocks
• When the buttocks are distending the perineum
the woman is placed in the lithotomy position.
• Then the vulva is swabbed and draped with
sterile towels
• The bladder must be empty
• Perineum is infiltrated with up to 10ml of 0.5%
plain lignocaine prior to an episiotomy.
• The woman is encouraged to push with the
contraction and the buttocks are delivered
spontaneously.

78. Cont…
• If the legs are flexed the feet disengage at the
vulva and the baby is born as far as the
umbilicus.
• The loop of cord is gently pulled down to
avoid traction on the umbilicus after checking
its pulsation.
• Then feel the elbows which are usually on the
chest. If so the arms will escape with the next
contraction. If the arms are not felt they are
extended.

79. Cont…
2. Delivery of the shoulder
• The uterine contractions and the weight of the
baby will bring the shoulders down on to the
pelvic floor.
• Wrap a small sterile towel around the baby’s hips
which preserves warmth and improves the grip
on the slippery skin.
• The midwife now grasps the baby by the iliac
crests with her thumbs held parallel over his
sacrum and tilts the baby towards the maternal
sacrum in order to free the anterior shoulder.

80. Cont…
• When the anterior shoulder has escaped the
buttocks are lifted towards the mother’s
abdomen to enable the posterior shoulder and
arms to pass over the perineum.
• As the shoulders are born the head enters the
pelvic brim with the sagittal suture in the
transverse diameter.
• The back must remain lateral until this has
happened but will after wards be turned
uppermost.
• If the back is turned upwards too soon the antero
posterior diameter of the head will enter the
antero posterior diameter of the brim (instead of
transverse diameter) and may become extended.

81. Cont…
3. Delivery of the flexed head by Burns Marshal
method.
Steps
A. After the shoulder are born the baby allowed to
hang unsupported with in one minute until the
nape of the neck (hairline) appears.
B. Then with the left hand the baby is grasped on
the ankles.
C. Right hand guards the perineum
D. Then the baby kept straight towards the mother
abdomen with sufficient traction and lifted in a
circular movement to allow chin and face to
sweep the perineum.

82. Cont…
Common complications of breech delivery and it’s
management
1. Delivery of extended legs
Diagnosis
• On vaginal examination no feet felt and buttock
firm to touch, round, smooth and external
genitalia evident.
• The frank breech descends more rapidly during
labour due to well fitting presenting part and also
the cervix dilates more quickly.
• Delay may occur at the out let because the legs
splint the body and impede lateral flexion of the
spine.

83. Cont…
Technique to deliver extended legs (By pinard
maneuver)
• If the buttocks are not expelled slight groin
traction can applied by inserting the finger in the
fold of the groins during uterine contraction
• When the popliteal fossa 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
(abducting the hip) and the knee is flexed by the
pressure on it’s under surface.
• This makes the lower part of the leg will emerge
in to the vagina

84. Cont…
2. Delivery of extended arms
Diagnosis
• When the elbow are not felt on the chest after
the umbilicus is born.
• This may be deal with by using the lovset
maneuver.
• This is a combination of rotation and downward
traction which may be employed to deliver the
arms what ever position they are in the direction
of rotation must always bring the back upper
most and the arms are delivered from under the
pubic arch

85. Cont…
Technique to deliver extended arms (Lovset
maneuver)
A. When the umbilicus is born and the shoulders
are in the anteroposterior diameter the baby
is grasped by the iliac crests with the thumbs
over the sacrum. Down ward traction is
applied until the axilla is visible.

86. Cont…
B. By maintaining gentle down ward traction rotate half a
circle (1800) starting by turning the back uppermost.
C. Assist delivery of the first arm under syp by inserting
two fingers of the hand and draw it down over the
chest as the elbow of the baby is flexed.
D. Then turn the back upper most and rotate 1800 in the
opposite direction of the first rotation by applying
gentle down ward traction.
E. Assist delivery of the second are under syp in the same
way of the first arm.

87. Lovsets manuver

88. Cont…
3. Delivery of the extended head (Arrest of the
after coming head)
• Delivery by maurceau – smellie veit maneuver.
This is jaw flexion and shoulder traction
• Also arrest of the after coming head assisted by
forceps delivery (piper forceps)
Technique of maurceau – smellie – veit maneuver
(MSV)
A. The baby is laid a astride the right arm with the
palm supporting the chest.
B. Two fingers of the right hand inserted on to the
baby’s maxilla to pull the jaw down wards and
flex the head.

89. Cont…
C. Two fingers of the left had are hooked over
the shoulders with the middle finger pushing
up the occiput to aid flexion.
D. Then traction is applied to draw the head out
of the vagina.
E. At the same time appropriate suprapubic
pressure applied by an assistant is helpful in
delivery of the head

90. Msv manuver

91. Cont…
Prague maneuver
• Delivery of the after coming head using the
modified Prague maneuver necessitated by
failure of the fetal trunk to rotate anterior.
• The modified maneuver as practiced today
consists of two fingers of one hand grasping
the shoulders of the back down fetus from
below while the other hand draws the feet up
over the maternal abdomen.

92. Cont…
Recommendation for C/S
• Cesarean delivery is commonly but not
exclusively used in the following circumstance
1. A large fetus
2. Any degree of contracted pelvis
• 3. A hyper extended head
4. No labor in PIH and ruptured membranes for 12
hours or more
5. Uterine dysfunction
6. Footling presentation
7. PTL

93. Cont…
8. Sever IUGR
9. Previous prenatal death
10. A request for sterilization
Complication of breech presentation
1. Impacted breech
• Labour becomes obstructed when the fetus is
disproportionately large for the size of the maternal pelvis.
2. Cord prolapse
• This is more common in a flexed or footling breech as these
have ill fitting presenting parts.
3. Superficial tissue damage
• Edema and bruising of the baby’s genitalia
• Discolored and edematous of the footling breech

94. Cont…
4. Fractures of humerus, clavicle, femur, dislocation
of shoulder or hip – caused during delivery of
extended arms or legs.
5. Erb’s palsy
• - Caused by the brachial plexus being damaged
by twisting the neck.
6. Trauma to internal organs
• - Especially a ruptured liver or spleen or adrenals
caused due to grasping of the abdomen.
7. Fracture of the spinal cord
• Caused by bending the body backwards over the
syp while delivering the head.

95. Cont…
8. Intra cranial hemorrhage
• Caused by rapid delivery of the head which has had no
opportunity to mould.
9. Fetal hypoxia
• This may caused due to intra cranial hemorrhage,
compression of the cord and or premature separation of
the placenta.
10. Premature separation of the placenta
11. Aspiration – because baby stimulated to birth before the
head is born.
12. Maternal trauma
13. Prolonged labour
14. More interference
15. Operative delivery
16. Infection

96. Cont…
4. Shoulder presentation
Defn When the fetus lies with its long axis
across the long axis of the uterus (transverse
lie) the shoulder is most likely to present.
• It occurs 1 in 300 pregnancies near term.
• The head lies on one side of the abdomen
with the breech at a slightly higher level on
the other
• The fetal back may be anterior or posterior
• The denominator is the acromion process.

97. Cont…
Causes
1. Lax abdominal and uterine muscles
• This is the most common cause and is found in
multigravida mother.
2. Uterine abnormality
A bicornute or subseptate uterus may result in a
transverse lie
3. Contracted pelvis
• This may prevent the head from entering the
pelvic brim
4. Preterm pregnancy

98. Cont…
• The amount of amniotic fluid in relation to the
fetus is greater allowing the fetus more
mobility than at term.
5. Multiple pregnancies
• It is the second twin which more commonly
adopts this lie after delivery of the first fetus.
6. Polyhydramnios

99. Cont…
• The distended uterus is globular and the fetus
can move freely in the excessive liquor.
7. Macerated fetus
• Lack of muscle tone causes the fetus to
slump down in to the lower pole of the uterus.
8. Placenta praevia
• This may prevent the head from entering the
pelvic brim

100. Cont…
Diagnosis
A. On abdominal palpation
• The uterus appears broad and the fundal
height is less than expected for the period of
gestation.
• On pelvic and fundal palpation neither head
nor breech is felt.
• The mobile head is found on one side of the
abdomen and the breech at a slightly higher
level on the other.

101. Cont…
B. On vaginal examination
• If the labour has been in progress for
sometime the shoulder may be felt as a soft
irregular mass. It is sometimes possible to
palpate the ribs.
• When the shoulder enters the pelvic brim an
arm may prolapse this is diagnostic.

102. Cont…
Possible out come
• There is no mechanism for delivery of a
shoulder presentation. If this persists in labour
delivery must by c/s to avoid obstructed labour
and subsequent uterine rupture.
• If the fetus is quite small (< 800gm) and the
pelvis is large spontaneous delivery is possible
despite persistence of the abnormal lie.

103. • The fetus is compressed with the head forced
against the abdomen.
• A portion of the thoracic wall below the
shoulder thus becomes the most dependent
part appearing at the vulva.
• The head thorax then pass through the pelvic
cavity at the same time and the fetus which is
doubled up on itself ( conduplicato corpore) is
expelled

104. Cont…
Management
• External version may be attempted by Dr
when transverse lie is diagnosed at 36 weeks
of gestation during antenatal visits. (not
recommended currently)
• If external version fails requires elective c/s

105. Cont…
• If a transverse lie detected in early labor while
the membrane is intact doctor may attempt
an external version if this is successful by a
controlled rupture of the membranes to
prevent card prolapse.
• If the membranes have already ruptured c/s is
necessary.

106. Cont…
Immediate caesarean section must be
performed if
• The cord prolapses
• When the membranes are already ruptured
• When external version is unsuccessful
• When labour has already been in progress for
some hours.
• Arm is prolapse even with dead fetus because
of danger of rupture uterus.

107. Cont…
Complications
1. Prolapsed cord
• .This may occur when the membranes rupture.
2. Prolapsed arm
• This may occur when the membranes have
ruptured ahs the shoulder has become impacted
• delivery should be by immediate c/s. Whether
the fetus is alive or dead as attempts at
manipulative procedures or destructive
operations can be dangerous for the mother and
may result in uterine rupture.

108. Cont…
3. Obstructed labour
4. Rupture of the uterus
5. IUFD