MALPOSITION of fetus during labour process

different abnormal positions of fetus during labour

1. MalpositionsMalpositions
Manveet kaur
Nursing tutor

4. INTRODUCTION
There are two terms that are used to refer to how
the baby is located in the mother's body,
presentation and position.
 
 presentation
 properly refers to which part of the
baby 'presents' first at the vagina; in other words
, whether the baby is head-up (breech), head-down
(vertex), or shoulder-first/sideways (transverse).

5. Position usually refers to how the back
of the baby's head is lying in reference
to the mother's spine (towards her spine
or away from it, etc.).
  

6. Difference
Malpresentation are those in which the
baby's head does not present at the cervix
first.
 
Malpositions in contrast, all present with the
head down BUT may not be situated
  in the
way that is most optimal for birth.

7. Definition
When the relationship between the
denominator of the presentation and point on
the pelvis is other than iliopectineal
eminence, then it is known as malposition.

8. TYPES OF MALPOSITIONS
Occipito-posterior position
Deep transeverse arrest

9. Occipito-posterior position
In a vertex presentation where the occiput is
placed posteriorly over the sacro-iliac joint or
directly over the sacrum is called Occipito-
posterior position
The presenting part is – vertex
The denominator is – occiput

10. Types
Right occipito-posterior position (ROP)– when
the occiput is placed over the right sacro-iliac
joint. Also called 3
rd
position of vertex.
Left occiput- posterior (LOP)- When the
occiput is placed over the left sacro-iliac joint.
Also called 4
th
posion of vestex.
Direct occipito-posterior – when it points
towards the sacrum.

11. Causes
Maternal factors
oAnthropoid pelvic brim
Android pelvic brim
Fetal factors--marked deflection of fetal head
caused by
High pelvic inclination
Attachment of placenta over the anterior wall of
the uterus.
Uterine factors
Abnormal uterine contractions

12. CLINICAL FEATURES
Days of tiring pre-labor or 'false' labor before
‘true’ labor; mother may begin labor exhausted
A tendency towards post-mature (long)
pregnancies and ‘overdue’ babies
A baby that does not engage before or even
well into labor
 
Feeling lots of hands and feet in front by the
mother's belly

14. PROM - Premature Rupture of Membranes, or
the bag of waters breaking before labor starts
Difficulty finding the baby's heart tones where
you usually would find them
'Stalled labor' - labor that stops between 4-7
cm and does not progress
Prolonged labor, especially in the pushing
stage

15. 'Back labor' - painful contractions felt mostly in
the back; common with posterior labors
because the baby's back is pressing against
the sacrum (low back); also found with the
arm across the baby's face because the arm is
pressing on the mother's sacrum .
High need for pain medication, since the pains
are abnormally difficult
'Early transition' - showing the signs of
transition (nausea, chills, high pain levels,
shakiness, etc.) between 4-7 cm instead of
between 7-10 cm

16. 'Fetal distress' - baby's heart rate has
problems because baby is stuck and gets
stressed; this may also increase incidence of
fetal meconium in labor
'Early pushing' - feeling the urge to push
before being fully dilated
'Anterior lip' - dilating to about 9.5 cm but a
small 'lip' of the cervix is stubbornly left

17. 'Stuck baby' - a baby that gets stuck before
passing the ischial spines (0 station) and does
not descend even after hours of pushing
Great pain with pushing, especially on one side
or another.

18. Diagnosis
Abdominal examination
Inspection – the abdomen looks flat , below
the umbilicus.
Umbilical grip –
1. the fetal limbs are more easily felt near the
midline on either side.
2.the fetal back is felt far away from the
midline on the flank and difficult to outline.
3.the anterior shoulder lies far away from the
midline.

19. Cont…..
 Pelvic grip –
1.head is not engaged .
2.the cephalic prominence (sinciput) is not felt
so prominent as found in well flexed occipito-
anterior.
Auscultation – the maximum intensity of fetal
heart sounds is heard on the flank and often
difficult to locate.

20. Vaginal examination –

1. Elongated bag of membranes which is likely to
rupture during examination .
2.The sagittal suture occupies any of the
oblique diameter of pelvis.
3.posterior fontanelle is felt near the sacro iliac
joint.
4.The anterior fontanelle is felt more easily
because of deflection of the head and at times ,is
felt at a lower level than the posterior one.

21. Cont….
Imaging – U/S is rarely done . It is helpful to
know the descent. Attitude of the head and its
relation to the pelvic walls (position).

22. GENERAL MANAGEMENT
Make a rapid evaluation of the general condition of
the woman including vital signs (pulse, blood
pressure, respiration, temperature).
Assess fetal condition:
- Listen to the fetal heart rate immediately after a
contraction:
- Count the fetal heart rate for a full minute at least
once every 30 minutes during the active phase
and every 5 minutes during the second stage;
- If there are fetal heart rate abnormalities (less
than 100 or more than 180 beats per minute),
suspect fetal distress.

23. Cont…
If the membranes have ruptured, note the
colour of the draining amniotic fluid:
Presence of thick meconium indicates the need
for close monitoring .
Absence of fluid draining after rupture of the
membranes is an indication of reduced volume
of amniotic fluid, which may be associated with
fetal distress.

24. Mechanism of labour
Diameter of engagement –oblique diameter
Engaging diameter of head – occipito
frontal(11.5cm),or suboccipito frontal (10cm)
favorable unfavorable
good uterine week pain
contractions android pelvis

Increasing flexion engagement delayed
With engagement

25. Cont…
Long anterior internal deflection
rotation of the occiput persists
(3/8
th
of circle). And
anterior shoulder by
(2/8
th
of circle).
Delivery of head by descent up to
extension. Pelvic floor

26. Cont……..

restitution(1/8
th
circle)
mild moderate severe
deflexion deflexion
ant.rot of non rot.of post.rot of
occiput occiput occiput
(1/8circle)
External rot.
(1/8thcircle)

27. Cont…….
deep oblique occipito
transverse posterior sacral
arrest arrest position

face to pubis arrest

delivery

29. Management of labour
Principles : (1) early diagnosis
(2) Strict vigilance
(3) Judicious and timely interference
First stage of labour
The labour is allowed to proceed in a manner similar to normal
labour. The following are special instructions..
(1)Anticipating prolonged labour : I/v line is sited and ringer
solution drip is started.
(2)Progress of labour is judged by : (a) progressive descent of
head.
(b)rotation of head and the anterior shoulder towards the
midline.

30. Cont…
© Increasing flexion of head.
(d) Position of sagittal suture on vaginal examination.
(e) Cervical dilatation.
(3) Weak pain /, persistence of deflexion and non
rotation of occiput (triad condition) : oxytocin drip is
started.
(4) Indication for labour : labour arrest , incordinate
uterine action , fetul distress.

31. Second stage of labour : in majority anterior
rotation of the occiput is completed and the
delivery is either spontaneous or with
insturments.
In minority there is malrotation or unrotation :
requires strict vigilance , episiotomy is to be
given to prevent perineal tear

32. Cont…
Third stage of labour : due to prolongation of
labour , tendency of postparrtum haemorrhage by
prophylactic I/V ERGOMETRINE 0.25mg . With
the delivery of anterior shoulder.

33. Deep transverse arrest (DTA)
The head is deep into the cavity ; the sagittal
suture is placed in the transverse bispinous
diameter and is no progress in descent of the
head even after the 1/2hr. Following full
dilatation of cervix.
The arrest in occipito transverse position may
be the end result of incomplete anterior
rotation of oblique occipito posterior position
or it may be due to non rotation of the
commonly primary occipito transverse
position of normal mech. OF labour.

35. CAUSES
(a)Faulty pelvic architecture such as prominent
ischial spines, flat sacrum and convergent
sidewalls.
(b)Deflection of the head.
©Weak uterine contractions
(d)Laxity of pelvic floor muscles.

36. DIAGNOSIS
(a)The head is engaged.
(b)The sagittal suture lies in the transverse
bispinous diameter.
©The anterior fontanelle is palpable.
(d)Faulty pelvic architecture.

37. •
MANUAL ROTATION
Requirement
The pt. is put under the general anaesthesia
Position-Lithotomy
Maintain surgical asepsis
Catheterise bladder
Vaginal examination

40. TYPES
Whole hand method:Whole of the hand is
introduced inside the vagina for rotation.
Steps:1.Gripping of the head
2.Rotation of the head
3.Application of forceps
DANGERS:Failure of the grip of head due to
lack of space.
Failure to dislodge the head from the impacted
position.

41. CONT…..
Half hand method-In this method,the 4
finger fingers and not the thumb is
introduced into the vagina.
Merits:Less space is required.
Less chance to displacement of the
head.
Steps:Four fingers of right hand and
tangential pressure is applied on the
head at the level of diameter of
engagement.

42. SUMMARIZATION
Introduction
Definition
Types of malpositions
Causes of malpositions
Clinical features of malpositons
Mechanism of labour
Management
Dep transeverse arrest