Malpresentation and Position

Question 1

What is different about the engagement for primips and multips?

Answer 1

Primip = head can engage and then disengage several times
Multip = once head is engaged, usually stays there

Question 2

What are some of the causes of OP position?

Answer 2

• Maternal lifestyle (e.g. slouching on sofa)
• Android/anthropoid pelvis
• Anterior placenta
• Epidural and synto
• Primip

Question 3

How can OP position be diagnosed antenatally?

Answer 3

• Dip near umbilicus
• Palpation
• FH auscultation

Question 4

How can OP position be diagnosed in labour?

Answer 4

• Back pain/ urge to push early
• Inspection and palpation
• VE
• Progress of labour (e.g. early SROM, incoordinate contractions)

Question 5

Why do OP babies often have an IOL?

Answer 5

Go to postdates as head can’t descend so labour isn’t initiated

Question 6

Describe long rotation

Answer 6

• Flexion on descent
• Occiput rotates forwards at pelvic floor
• Head now in same position as OA
• Shoulders follow and head born by extension

Question 7

Describe short rotation

Answer 7

• Descent with little/no flexion
• Sinciput rotates forwards at pelvic floor (now in direct OP)
• Occiput passes into hollow of sacrum
• Shoulders enter pelvis in L oblique
• Occiput born by extension

Question 8

What is deep transverse arrest?

Answer 8

• Head descends with some flexion
• Flexion no maintained and head caught in bi-spinous diameter
• Head cannot deliver

Question 9

What are some of the risks associated with OP delivery?

Answer 9

• DTA
• Maternal exhaustion
• Increased risk of epidural/ instrumental/ CS
• Cord prolapse
• Excessive moulding/ haemorrhage
• Hypoxia

Question 10

What are some of the causes of face presentation?

Answer 10

• Polyhydramnios
• Enlargement of foetal neck
• Multiple coils of cord around neck
• Anencephaly
• Multiple pregnancy
• Prematurity

Question 11

How can face presentation be diagnosed?

Answer 11

• Deep groove between head and back palpable

- VE (PP high, eyes/ nose/ mouth felt

Question 12

What position must babies rotate to in order to have a successful vaginal delivery from face presentation?

Answer 12

Mento-anterior

Question 13

What are some of the complications associated with face presentation?

Answer 13

• Cord prolapse
• Obstructed labour
• Foetal distress
• Severe perineal trauma
• Facial bruising and oedema

Question 14

How can brow presentation be diagnosed?

Answer 14

• Large, non-engaged head on palpation
• PP high
• Anterior fontanelle felt on one side and orbital ridges on other
• No descent

Question 15

What are some of the risks associated with brow presentation?

Answer 15

• Cord prolapse
• Foetal distress
• Excessive moulding
• Obstructed labour

Question 16

What type of presentation is immediately considered an obstetric emergency?

Answer 16

Shoulder presentation or Deep Transverse Arrest

Question 17

What are the 4 types of breech presentation?

Answer 17

1. Complete (flexed) - both legs bent
2. Frank (extended) - both legs straight up
3. Incomplete - one leg bent, one leg up
4. Kneeling
5. Footling

Question 18

When should an ECV be performed?

Answer 18

Primip = 36/40
Multip = 37/40

Question 19

What are some contraindications for an ECV?

Answer 19

• Placenta praevia
• Multiple pregnancy
• Rhesus isoimmunisation
• SROM
• IUD
• Preeclampsia

Question 20

What is internal podalic version?

Answer 20

Inserting the hand into the vagina and pulling the foot down on a breech baby - most commonly used to deliver 2nd twin

Question 21

How should a breech baby be delivered?

Answer 21

• Hands-off where possible
• Hands on bony prominences only to reduce injuries
• Episiotomy only if required

Question 22

How are the legs delivered in breech presentation?

Answer 22

Leave the baby to deliver naturally. If baby gets stuck at hips, apply pressure to popliteal fossae to deliver the legs

Question 23

How are the shoulders delivered in breech presentation?

Answer 23

Lovsett’s maneouvre:

• Hold bony prominences of hips and rotate 90 degrees
• Use a hand to release the arm
• Repeat this in the other direction

Question 24

How is the head delivered in breech presentation?

Answer 24

Mariceau Smellie-Viet maneouvre:

• Use forearm to support baby’s body
• Place a finger on each cheekbone
• Use the other hand to apply pressure to the occiput and then encourage flexion to deliver the baby up and onto the mother

Question 25

When should a presentation scan be booked antenatally?

Answer 25

- Breech on palpation - Unstable lie - Unsure of presentation at 36/40 or later

Question 26

What is the postnatal management for a baby that was breech any time after 36/40?

Answer 26

Hip scan