MALPRESENTATION Presented By :

Dr. Nico Poundra Mulia

Moderator :

Dr. Fatmah Oktaviani, SpOG

Book Reading

KEYPOINTS• Malpresentation associated with uterine anomalies,

fibroids, placenta previa, grand multiparity, pelvic tumors, prematurity, multiple gestation, polyhydramnios, short umbilical cord, fetal anomalies, prior breech delivery.

• Complications of breech presentation congenital anomalies, preterm birth (PTB), birth trauma, low Apgar scores, cord prolapse

DEFINITIONS• Presentation Fetal body part that is

in the lower uterine segment (lowest in the uterus and closest to the cervix).

• Malpresentation Fetus presenting with the fetal head not in the lower uterine segment.

MALPRESENTATION

Symptoms

• Maternal impression of fetal presentation based on fetal movementis suggestive but overall unreliable for predicting fetal Presentation

Epidemiology/Incidence

• Breech presentation complicates 3% to 4% of all pregnancies at term (37 weeks).

CLASSIFICATIONS

• Breech

Fetus presents in longitudinal lie with head not in the lower uterine segment.

Fetal breech presentation is further classified as follows:• Complete—Flexion of the fetal hips and knees• Incomplete—Extension of one or both hips (includes footling)• Frank—Flexion at the hips and extension at the knees

CLASSIFICATIONS

• Transverse

The fetal longitudinal axis is perpendicular to the long axis of the uterus. The fetus can either present “back up” (fetal small parts present to the cervix), or “back down” (fetal spine or shoulder present to the cervix).

• Oblique

The fetal longitudinal axis is diagonal to the long axis of the uterus.

• Face

The fetal head is hyperextended so that the fetal occiput is in contact with the fetal back and the mentum (chin) is presenting.

CLASSIFICATIONS

• Brow

The presenting part is the portion of the fetal head between the orbital ridge and the anterior fontanel.

• Compound

Simultaneous presentation of a prolapsing fetal extremity and the presenting part.

RISK FACTORS/ASSOCIATIONS

• Uterine anomalies, fibroids, placenta previa, grand multiparity, contracted maternal pelvis, pelvic tumors, prematurity, multiple gestation, polyhydramnios, short umbilical cord, fetal anomalies, and prior breech delivery.

• Prior breech delivery gives a 9% risk of recurrence in subsequent pregnancies.

COMPLICATIONS

• Incidence of congenital anomalies (up to 6%), PTB, birth trauma, low Apgar scores, and lower pH are higher with a breech presentation compared with a vertex presentation

• Breech presentation a sign and a consequence of fetal compromise, again regardless of delivery mode.

WORKUP

• Fetal presentation should be assessed by Leopold’s maneuvers at each visit starting at 34 weeks of gestation.

• If the clinician is unsure, a vaginal examination, or even better, if still unclear, an ultrasound is indicated to assess fetal presentation.

EXTERNAL CEPHALIC VERSION

• Procedure performed by application of pressure and maneuvers to the maternal abdomen with the goal to turn the fetus to a cephalic presentation

• Complications short-term fetal bradycardia is as high as 20% or more, the rate of need for urgent CD for NRFHT after an ECV is about 1/600.

• Placental abruption (<1%)

• Contraindications• Any contraindications to vaginal delivery such as placenta previa or prior

classical uterine incision

• Efficacy• ECV at term is associated with reduction in noncephalic birth and decrease in

CD.

• Timing of version• Compared with no ECV attempt, ECV before term reduces noncephalic births.

• Tocolysis. • betamimetics prior to attempt at ECV is associated with 26% fewer failures of

ECV. • Terbutaline 5 mg subcutaneously once, 10 to 15 minutes before ECV, • Intravenous salbutamol tocolysis prior to ECV increased success rates,

decreased CD rate, and was well tolerated.

• Tocolysis can be used with success also in a second ECV attempt after a first ECV attempt has failed

• Nitroglycerin improve version success rates.

• Nifedipine did not significantly improve the success of ECV

• Fetal acoustic stimulation to the fetal head for 1 to 3 seconds in midline fetal spine positions fewer failures of ECV at term

• The success rate in the control group of this study was much lower than expected (8%).

• The evidence is insufficient to make a recommendation.

• Anesthesia• There is limited convincing evidence that regional anesthesia affects ECV

success. • ECV failure, noncephalic births, and cesarean sections were reduced in two

trials with epidural

• ECV success rates increased from 33% to 59% with epidural in one study and from 32% to 69% in another.

• ECV procedure Given the possible complications, it is prudent to perform ECV in a facility with ready availability for emergency CD.

• Consent should be obtained after counseling regarding possible complications.

• A nonstress test should be performed before and after the procedure.

• Betamimetic prophylactic tocolysis should be given (e.g., terbutaline 5 mg subcutaneously 5 to 10 minutes prior to procedure).

MOXIBUSTION AND/OR ACUPUNCTURE

• Moxibustion is a form of traditional Chinese medicine that uses heat generated by burning herbs

• There is inconsistent evidence to assess if the use of moxibustion significantly converts a breech to a cephalic presentation.

• A more recent small RCT reported no beneficial effect of moxibustion to facilitate ECV with the percentage of versions similar between moxibustion (18%) and controls (16%).

MATERNAL CHANGE IN POSTURE

• Maternal change in position such as knee-chest suggested as a means to correct breech presentation in pregnancy.

• There is insufficient evidence from the small trials reported so far to support the use of postural management for breech presentation.

• Meta-analysis of these data could not be done as study designs and outcomes measured were different.

DELIVERY OUTCOMES

• The rate of CD after ECV is still about double that of pregnancies presenting with spontaneous cephalic presentation because of higher incidences of dystocia and NRFHT after successful ECV.

MODE OF DELIVERY

• Singleton Term• Term breech. Three RCTs (39), including one large study , have

compared a policy of planned CD to a policy of planned trial of labor to attempt a vaginal delivery.

• CD occurs in about 45% of those women allocated to a vaginal delivery protocol and >90% in those allocated to a CD protocol.

• At three months after delivery, women allocated to the planned cesarean section group reported 38% less urinary incontinence; 89% more abdominal pain; and 68% less perineal pain.

Technical aspects.

• Cesarean breech delivery: There are no trials to assess technical aspects of breech (or other malpresentation) CD.

• There is insufficient evidence to assess if intra-abdominal version during CD before uterine incision affects outcomes.

• Vaginal breech delivery several technical suggestions for assisting a vaginal breech delivery.

PRETERM

The premature breech

• There is insufficient evidence to assess if outcomes of the preterm fetus presenting breech are affected by mode of delivery.

• Very little prospective data, mostly nonrandomized, exists regarding vaginal versus CD of the premature breech infant.

TWINS

• Pregnancies at 35 to 43 weeks with vertex/breech presentation in twin gestations <7 cm dilated have similar Apgar scores or incidence of neonatal morbidity in the second twin if delivered by vaginal or cesarean birth in a very small trial.

• No incidence of birth trauma or IVH in any of the 27 breech deliveries.

• Maternal febrile morbidity and length of stay was increased in the cesarean group

THANK YOU