FETAL MALPRESENTATIONS AND MALPOSITIONS

A SEMINAR

PRESENTED

BY

UCHANMA FAVOUR CHIDINMA.

IN PARTIAL FULFILMENT OF THE COURSE: NSC 522 SEMINAR IN NURSING

MAY, 2024

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 CERTIFICATION
This is to certify that this seminar project by UCHANMA FAVOUR CHIDINMA with matric
number 2018/ 117837/REGULAR has been examined and approved for the award of Bachelor of
nursing science.

__________________________ ______________
Mrs. Ukeagu N.C Date
(Supervisor)

____________________________ ______________
Dr. Mrs. Emeonye O.P Date
(HOD)

____________________________ _______________
EXTERNAL EXAMINER Date

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 DEDICATION
This seminar work is dedicated to the almighty God for keeping me till this stage and seeing me
through the process of this work. I am grateful.

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ACKNOWLEDGEMENT

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 TABLE OF CONTENTS
Title i

Certification ii

Dedication iii

Acknowledgement iv

Table of contents v

Introduction 1

Concept of Fetal Malpresentations and Malposition 3

Risk Factors 5

Identifying Fetal Lie, Presentation and Position 5

Management of Abnormal Fetal Lie 6

Management of malpresentations 6

Management of malpositions 7

Conclusion 8

Summary 9

Reference 11

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 ABSTRACT

This seminar delves into the critical aspects of fetal orientation during pregnancy, particularly

focusing on non-standard presentations and positions that may arise. It outlines the definitions

and clinical significance of fetal lie, presentation, and position, emphasizing their importance in

labor and delivery. It further discusses the risk factors associated with these abnormalities, such

as prematurity and uterine anomalies, and the methods for identification through abdominal and

vaginal examinations. Management strategies, including external cephalic version (ECV) and

considerations for cesarean section, are also explored. The article serves as an informative guide

for understanding and addressing the complexities of fetal orientation in obstetric care.

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 INTRODUCTION

Fetal malpresentations and malpositions are significant concerns in obstetrics, as they can lead to

complications during childbirth. Malpresentation refers to the position of the fetus in the womb

that is not ideal for delivery, such as breech, face, brow, or shoulder presentations, rather than the

normal head-down (vertex) position. Malposition, on the other hand, describes the orientation of

the fetus within the uterus, such as when the baby's head is facing the mother's back (occiput

posterior) or side (occiput transverse), rather than the optimal occipito-anterior position. These

conditions can affect the labor process and may necessitate medical interventions like external

cephalic version, where the baby is manually turned to a head-down position, or a cesarean

delivery to ensure the safety of both mother and child. Understanding these terms is crucial for

healthcare professionals and expectant mothers to prepare for and address any challenges that

may arise during delivery.

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Objectives of the seminar

At the end of this seminar, the participants should be able to;

1. Define and differentiate between fetal lie, malpresentation, and malposition.

2. Recognize the various risk factors that can lead to abnormal fetal lie, malpresentation,

and malposition, such as prematurity and uterine abnormalities.

3. Learn the proper techniques for identifying fetal lie, presentation, and position through

abdominal and vaginal examinations

4. Understand the management of abnormal fetal lie and malpresentation, including the use

of external cephalic version (ECV) and the indications for cesarean section.

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Concept of Fetal Malpresentations and Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

Definitions

Lie – the relationship between the long axis of the fetus and the mother.

 Longitudinal: In a longitudinal lie, the fetal longitudinal axis aligns with the long axis of

the uterus.

- The presentation can be either cephalic (head-first) or breech (buttocks-first).

 Transverse: In a transverse lie, the fetal longitudinal axis lies perpendicular to the long

axis of the uterus. There are two configurations:

- The curvature of the fetal spine is oriented downward, and the fetal shoulder presents

at the cervix.

- The curvature of the fetal spine is oriented upward, and the fetal small parts and

umbilical cord present at the cervix.

 Oblique: An oblique lie is an unstable position that will eventually become either

transverse or longitudinal.

- The presentation in an oblique lie is usually the shoulder or the arm.

Presentation – the fetal part that first enters the maternal pelvis.

Cephalic Vertex Presentation:

- This is the most common and safest presentation.

- In a cephalic vertex presentation, the baby’s head is positioned downward, ready to enter

the birth canal first.

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 - The baby’s neck is slightly flexed, allowing the smallest part of the head (the vertex) to

lead the way.

Breech Presentation:

In a breech presentation, the baby’s buttocks or feet are positioned to enter the birth canal first.

Breech presentations can be:

- Frank breech: The baby’s buttocks are down, and the legs are flexed at the hips, with

feet near the head.

- Complete breech: Both the baby’s buttocks and feet are down, with knees flexed.

- Footling breech: One or both feet are positioned to enter the birth canal first.

Shoulder Presentation:

- In a shoulder presentation, the baby lies sideways in the uterus, with one shoulder

presenting at the cervix.

- Shoulder presentations are rare and often require medical intervention.

Face Presentation:

- In a face presentation, the baby’s face is positioned to enter the birth canal first.

- This presentation is less common and may lead to prolonged labor.

Brow Presentation:

- A brow presentation occurs when the baby’s head is partially extended, with the forehead

presenting at the cervix.

- Brow presentations are also uncommon and may necessitate medical assistance.

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Position – the position of the fetal head as it exits the birth canal.

 Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing

anteriorly) – this is ideal for birth

 Other positions include occipito-posterior and occipito-transverse.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

- Prematurity

- Multiple pregnancy

- Uterine abnormalities (e.g fibroids, partial septate uterus)

- Fetal abnormalities

- Placenta praevia

- Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal

position is ascertained by vaginal examination.

Lie

- Face the patient’s head

- Place your hands on either side of the uterus and gently apply pressure; one side will feel

fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite

side

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Presentation

- Face the patient’s head

- Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the

head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)

- You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she

has not emptied her bladder, if the fetus is small or if there is polyhydramnios.

Position

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic

vertex presentation). The landmarks of the fetal head, including the anterior and posterior

fontanelles, indicate the position.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan.

This could also demonstrate predisposing uterine or fetal abnormalities.

MANAGEMENT OF ABNORMAL FETAL LIE

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally

between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

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 It has an approximate success rate of 50% in primiparous women and 60% in multiparous

women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous

women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress, premature rupture of membranes,

antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean

section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities

or a previous C-section.

External Cephalic Version

MANAGEMENT OF MALPRESENTATION

The management of malpresentation is dependent on the presentation.

 Breech – attempt ECV before labour, vaginal breech delivery or C-section

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  Brow – a C-section is necessary

 Face

- If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to

be prolonged and there is an increased risk of a C-section being required

- If the chin is posterior (mento-posterior) then a C-section is necessary

 Shoulder – a C-section is necessary

MANAGEMENT OF MALPOSITION

- 90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the

fetal head does not rotate, rotation and operative vaginal delivery can be attempted.

Alternatively a C-section can be performed.

Conclusion

In conclusion, understanding fetal lie, presentation, and position is crucial for successful labor

and delivery. Identifying risk factors, utilizing diagnostic techniques, and implementing

appropriate management strategies are essential components in obstetric care.

Summary

The topic of fetal lie, presentation, and position is a critical aspect of obstetrics, as it significantly

influences the labor and delivery process. Fetal lie refers to the orientation of the fetus in the

uterus, whether it is longitudinal, transverse, or oblique. Presentation denotes the part of the fetus

that is positioned to be delivered first, commonly the head (vertex) but sometimes the buttocks

(breech) or other parts. Position describes the specific orientation of the presenting part of the

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fetus within the pelvis, such as occiput anterior or posterior. Understanding these concepts is

essential for healthcare providers to anticipate and manage potential complications during

childbirth.

Risk factors for abnormal fetal lie and malpresentation include prematurity, multiple gestations,

uterine anomalies like fibroids, fetal anomalies, placenta previa, and a first pregnancy. These

conditions can complicate the delivery and may necessitate interventions such as external

cephalic version (ECV), where the fetus is manually rotated to a more favorable position, or

cesarean delivery in cases where vaginal delivery is deemed unsafe.

Diagnosis of fetal lie, presentation, and position is typically achieved through physical

examination, which may include both abdominal and vaginal assessments, and is often

confirmed with ultrasound imaging. This diagnostic process is crucial for planning the

appropriate management strategy to ensure the safety of both the mother and the fetus during

delivery.

References

Merck Manuals Professional Edition. (2018.). Fetal Presentation, Position, and Lie. Retrieved
from https://www.merckmanuals.com

MSD Manual Consumer Version. (2019.). Labor: Fetal Position and Presentation. Retrieved
from https://www.msdmanuals.com

MSD Manuals. (2021.). Fetal Presentation, Position, and Lie - International. Retrieved from
https://www.msdmanuals.com/international

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TeachMeObGyn. (2019.). Abnormal Fetal Lie, Malpresentation, and Malposition. Retrieved
from https://teachmeobgyn.com

SpringerLink. (2020.). Paget Disease of the Nipple. Retrieved from https://link.springer.com

Current Breast Cancer Reports. (2019.). Paget’s Disease of the Breast. Retrieved from
https://www.springer.com/journal/12609

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