2. 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.
3. 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
4. Types of Malpresentation
BREECH
Complete (Flexed) Breech Presentation
Footling Breech Presentation
Frank (Extended) Breech Presentation
Kneeling Breech Presentation
VERTEX
Brow Presentation
Face Presentation
Sincipital Presentation
TRANSVERSE
The diagnosis of abnormal fetal presentations is commonly made with
a combination of Leopold’s Maneuver, Vaginal examination, and
Ultrasound
5. Types of Malpresentation
BREECH
Breech presentation means that either the buttocks
or the feet are the first body parts that will contact the
cervix.
Breech presentations occurs 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.
6. Types of Breech Presentation
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.
Complete Breech
The baby's hips and knees are
flexed so that the baby is sitting
crosslegged, with feet beside the
bottom.
7. Types of Breech
Presentation
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.
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.
8. Maternal Risks
Prolonged 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.
9. 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.
10. Management
If the woman is in early labor and the
membranes are intact, attempt External
Cephalic Version.
Tocolytics, such as Terbutaline 0.25 mg IM,
can be used before ECV to help relax the
uterus.
If ECV is successful, proceed with normal
childbirth. If EVC fails or is not advisable,
deliver by caesarean section.
11.
12. Management
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 possible
Membranes 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).
13. Management
VAGINAL BREECH DELIVERY. 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.
14. Management
CESAREAN SECTION for breech presentation. A
cesarean section is safer than vaginal breech
delivery and recommended in cases of:
Double footling breech
Small or malformed pelvis
Very large fetus
Previous cesarean section for cephalopelvic
disproportion
Hyperextended or deflexed head.
15.
16. Types of Malpresentation
TRANSVERSE
In 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.
17. 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.
18. Types of Malpresentation
SINCIPUT
The sinciput presentation occurs
when the larger diameter of the fetal
head is presented. Labor progress is
slowed with slower descent of the
fetal head.
FACE
The face presentation is caused by
hyper-extension of the fetal head so
that neither the occiput nor the
sinciput is palpable on vaginal
examination.
19. Management
In 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.
20. Management
Chin-Anterior Position
If 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.
21. Types of Malpresentation
BROW
The brow presentation
is caused by partial
extension of the fetal
head so that the
occiput is higher than
the sinciput. MGT: If the fetus is alive or dead, deliver
by caesarean section.
*Do not deliver brow presentation by
vacuum extraction, outlet forceps or
symphysiotomy.
22. 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
25. Anxiety
Provide client and family teaching,
Be available to client for listening and talking
Provide client support and encouragement.
Encourage client to acknowledge and express feelings.
Encourage breathing exercises to relieve anxiety.
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.
26. Risk for Injury
Observe closely for abnormal labor patterns.
Monitor fetal heart beat and contractions continuously
Be 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.
Risk for infection
Stress 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.
27. Fetal Malposition
Refers to positions other than an
occipitoanterior position.
Malpositions include occipitoposterior and
occipitotransverse positions of fetal head
in relation to maternal pelvis.
It is usually seen in multipara or those with
lax abdominal wall. Fetal malpositions are
assessed during labor.
28. Left Occipitoanterior Rotation
• (A) A fetus in cephalic presentation, LOA position. View is from
outlet. The fetus rotates 90 degrees from this position. (B) Descent
and flexion (C) Internal rotation complete. (D) Extension; the face
and chin are born
29. Types of Fetal Malposition
Occipitoposterior Position
Arrested labor may occur when
the head does not rotate and/or
descend. Delivery may be
complicated by perineal tears or
extension of an episiotomy.
Occipitotransverse Position
It is the incomplete rotation
of OP to OA results in the fetal
head being in a horizontal or
transverse position (OT).
30. Left Occipitoposterior Rotation
• (A) Fetus in cephalic
presentation LOP
position. View is from
outlet. The fetus rotates
135 degrees from this
position. (B) Descent and
flewion. (C) In ternal
rotation beginning.
Because of the posterior
position, the head will
rotate in a longer arc
than if it were in an
anterior position. (D)
Internal rotation
complete. (E) Extension;
the face and the chin are
born. (F) External
rotation; the fetus
rotates to place the
shoulder in an
anteroposterior position
31. Diagnosis:
Abdominal examination – the lower part of the abdomen is flattened,
fetal limbs are palpable anteriorly and the fetal flank.
Vaginal examination – the posterior fontanelle is toward the sacrum and
the anterior fontanelle may be easily felt if the head is deflexed
Ultrasound
Maternal risks:
• prolonged labor
• potential for operative
delivery
• extension of episiotomy,
• 3rd or 4th degree
laceration of the
perineum.
Maternal symptoms:
• Intense back pain in labor
• Dysfunctional labor
pattern
• prolonged active phase
• secondary arrest of
dilatation
• arrest of descent
32. Nursing MGT
Encourage the mother to lie on her side from the fetal back, which may
help with rotation.
Pelvic – rocking may Knee – chest position
help with rotation. may facilitate rotation.
Apply sacral counter – pressure with heel of hand to relieve back pain.
Continue support and encouragement:
Keep client and family informed progress.
Praise client’s efforts to maintain control.
33. Management
• If there are signs of obstruction or the fetal heart
rate is abnormal at any stage, deliver by caesarean
section.
• If the membranes are intact, rupture the membranes
with an amniotic hook or a Kocher clamp.
• If the cervix is not fully dilated and there are no signs
of obstruction, augment labor with oxytocin.
• If the cervix is fully dilated but there is no descent in
the expulsive phase, assess for signs of obstruction.
34. Management
If the cervix is fully dilated
and if:
• the leading bony edge of the
head is above -2 station,
perform caesarean section;
• the leading bony edge of the
head is between 0 station and
-2 station, Delivery by Vacuum
Extraction and Symphysiotomy
• If the operator is not proficient in
symphysiotomy, perform
caesarean section;
• If the bony edge of the fetal head
is at 0 station, deliver by vacuum
extraction or forceps.
35. Management
SYMPHYSIOTOMY
A surgical procedure in
which the cartilage of the
symphysis pubis is divided to
widen the pelvis allowing
childbirth when there is a
mechanical problem.
Currently the procedure is
rarely performed in developed
countries, but is still routine in
developing countries where
cesarean section is not always
an option.
36. Management
Forceps - provides traction or a
means of rotating the fetal
head.
Risks: fetal ecchymosis or edema
of the face, transient facial
paralysis, maternal lacerations,
or episiotomy extensions.
Vacuum extraction - Provides
traction to shorten the second
stage of labor.
Risks: newborn cephalhematoma,
retinal hemorrhage and
intracranial hemorrhage.
37. Nursing Diagnoses:
Impaired gas exchange
Encourage the mother to lie on her side from the fetal back, which may help
with rotation.
Knee – chest position may facilitate rotation.
Pelvic – rocking may help with rotation.
Monitor FHB appropriately
Be prepared for childbirth emergencies such as cesarean section, forceps-
assisted delivery, and neonatal-resuscitation.
Pain
Encourage relaxation with contractions.
Apply sacral counter – pressure with heel of hand to relieve back pain.
Provide comfortable environment.
Teach breathing exercises for use during early labor until client receives
pharmacologic relief.
Monitor physical response for example, palpitations/rapid pulse
38. Nursing Diagnoses:
Fatigue
Assess psychological and physical factors that may affect reports of fatigue level
Monitor physical response for example, palpitations/rapid pulse
Monitor fetal heart beat and contractions continuously.
Refraining from intervening with client during contraction.
Anxiety
Keep client and family informed progress.
Provide support during labor through personal touch and contact. These
methods convey concern.
Continue support and encouragement.
Make the client feel she is somewhat in control of her situation.
Provide client and family teaching.
Identify client’s perception of the threat presented by the situation.
