MALPRESENTATION

1. Dr. S.K.S MALPRESENTATION

2. Face presentation

3. Definition:- The face of the fetus comes in the birth canal, when the head lies in the attitude of complete extension. • Face presentation comprises of mouth with alveolar margins, nose, eyes, mentum and malar eminences.

4. Position • Left mento-anterior- commonest • Right mento-anterior • Left mento-posterior • Right mento-posterior

6. Incidence: 0.2% • Mechanics of presentation: • Characterized by extreme extension of the fetal head so the face (rather than the skull) presents to the birth canal • Aetiology • Any factor that favours extension such as fetal goitre, anencephaly • High maternal parity

7. Diagnosis Abdominal examination :- Inspection :-there is no visible bulging of the flank, due to “S” shaped fetal spine. Palpation :- the diagnostic features in mento anterior and mento posterior are as follows:-

9. Vaginal examination:- • Generally diagnosed on vaginal examination in labour • The diagnostic features are palpating the mouth with hard alveolar margins, nose, malar eminences, supraorbital ridges and mentum.

11. May be confused with breech presentation REMEMBER • anus has sphincter tone & meconium stained, the mouth has sucking reflex. • anus is in line with the ischial tuberosities; mouth forms a traingle with the malar prominences Investigation :- USG to conform diagnosis and exclude fetal abnormalities.

13. Management • First stage :- • face presentation is conformed by abdominal and vaginal examination. • Fetal size, malformation and pelvis are assessed. • Partograph should be maintained. • Bed rest. • Maintain proper nutrition. • Sedation if necessary.

14. Face presentation • Second stage:- . Dead fetus Mento-anterior Mento-posterior LSCS • 90% case normal spontaneous vaginal (face to pubis) delivery with liberal episiotomy • If delay forceps delivery Craniotomy

16. Third stage:- Active management. • Complications:- • Maternal :- • Prolonged labour • High operative interference. • Fetus:- • cong. Malformation. • Hypoxia • Operative delivery • Laryngeal oedema.

17. Cause of delayed engagement in face presentation:- • long diameter i.e. sub mento-vertical. • No moulding. • Weak uterine contraction.

18. Brow presentation

19. Definition:- brow or forehead presents when fetal head lies midway between full flexion and full extension(deflexion head). • Incidence: 1:1400 • Position:- Mento - anterior brow Mento –posterior brow

20. BROW PRESENTATION • Mechanics of presentation: • head is extended such that attitude is halfway between flexion (vertex) and hyperextension (face) • usually transitional- when the head is in the process of converting from a vertex to a face or vice versa • presenting part is between the facial orbits and anterior fontanelle

22. Diagnosis • Abdominal examination:- Finding are same as face presentation except sinciput and the groove between it and back are less prominent. • Vaginal examination:- • anterior fontanelle • supra-orbital ridges • eyes

24. MANGEMENT IN LABOUR • Initially expectant; • 50-75% will either flex to a vertex, or extend to a face with contractions from behind meeting soft tissue and bony resistance below and will therefore deliver vaginally • High incidence of prolonged labour and dysfunctional labour • Persistent brow • the diameter is undeliverable vaginally • deliver by caesarean section