obstetrical condition

1. FETALFETAL MALPRESENTATIONMALPRESENTATION
andand
MALPOSITIONMALPOSITION
Joni Jabez O. AreolaJoni Jabez O. Areola
Ulysses E. Boglosa, Jr.Ulysses E. Boglosa, Jr.
Jennifer P. SedilloJennifer P. Sedillo

2. Fetal Malpresentation
Fetal malpresentationFetal 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. BREECH
Complete (Flexed) Breech Presentation
Footling Breech Presentation
Frank (Extended) Breech Presentation
Kneeling Breech Presentation
VERTEX
Brow Presentation
Face Presentation
Sincipital Presentation
TRANSVERSE
Types of Malpresentation
The diagnosis of abnormal fetal presentations is commonly made withThe diagnosis of abnormal fetal presentations is commonly made with
a combination ofa combination of Leopold’s ManeuverLeopold’s Maneuver,, Vaginal examinationVaginal examination,, andand
UltrasoundUltrasound

5. Types of Malpresentation
BREECHBREECH
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 breechFrank 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 BreechComplete 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 BreechFootling 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 BreechKneeling 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.

12. Attempt external version if: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).
Management

13. VAGINAL BREECH DELIVERYVAGINAL 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.
Management

14. 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.
Management

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. • 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.
Management

18. Types of Malpresentation
SINCIPUTSINCIPUT
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.
FACEFACE
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-anteriorchin-anterior
position prolonged
labor is common.
Descent and delivery of
the head by flexion may
occur.
In the chin-posteriorchin-posterior
position, however, the
fully extended head is
blocked by the sacrum.
This prevents descent
and labor is arrested.

20. Management
Chin-Anterior PositionChin-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 PositionChin-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 vacuumDo not perform vacuum
extraction for faceextraction for face
presentation.presentation.

21. Types of Malpresentation
BROWBROW
The brow
presentation is
caused by partial
extension of the
fetal head so that
the occiput is
higher than the
sinciput.
MGTMGT: 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

23. Fetal MalpresentationFetal Malpresentation
PathophysiologyPathophysiology

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 MalpositionFetal Malposition
Refers to positions other than an
occipitoanterioroccipitoanterior positionposition.
Malpositions include
occipitoposterioroccipitoposterior and
occipitotransverseoccipitotransverse 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 RotationLeft Occipitoanterior Rotation
• (A)(A) A fetus in cephalic presentation, LOA position. View is
from outlet. The fetus rotates 90 degrees from this position.
(B)(B) Descent and flexion (C)(C) Internal rotation complete. (D). (D)
Extension; the face and chin are born

29. Types of Fetal Malposition
Occipitoposterior PositionOccipitoposterior 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 PositionOccipitotransverse 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 RotationLeft Occipitoposterior Rotation
• (A)(A) Fetus in cephalic
presentation LOP
position. View is from
outlet. The fetus
rotates 135 degrees
from this position. (B)(B)
Descent and flexion.
(C)(C) Internal rotation
beginning. Because
of the posterior
position, the head
will rotate in a longer
arc than if it were in
an anterior position.
(D)(D) Internal rotation
complete. (E)(E)
Extension; the face
and the chin are born.
(F)(F) External rotation;
the fetus rotates to
place the shoulder in
an anteroposterior
position

31. Diagnosis:Diagnosis:
Abdominal examinationAbdominal examination – the lower part of the abdomen is
flattened, fetal limbs are palpable anteriorly and the fetal flank.
Vaginal examinationVaginal examination – the posterior fontanelle is toward the
sacrum and the anterior fontanelle may be easily felt if the head
is deflexed
UltrasoundUltrasound
Maternal risks:Maternal risks:
• prolonged labor
• potential for operative
delivery
• extension of
episiotomy,
• 3rd or 4th degree
laceration of the
perineum.
Maternal symptomsMaternal 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 fetalIf there are signs of obstruction or the fetal
heart rate is abnormal at any stageheart rate is abnormal at any stage, deliver by
caesarean section.
• If the membranes are intactIf the membranes are intact, rupture the
membranes with an amniotic hook or a
Kocher clamp.
• If the cervix is not fully dilated and there areIf the cervix is not fully dilated and there are
no signs of obstructionno signs of obstruction, augment labor with
oxytocin.
• If the cervix is fully dilated but there is noIf the cervix is fully dilated but there is no
descent in the expulsive phasedescent 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. 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.
Nursing Diagnoses:

39. Fetal MalpositionFetal Malposition
PathophysiologyPathophysiology

41. QUIZ TIME!!!!!!!!!!!!