NORMAL AND ABNORMAL PRESENT ION

ALSAFA
FETAL PRESENTATION

• is the portion of the fetal body that is either foremost within the birth canal or
in closest proximity to it.
• can be felt through the cervix during vaginal examination
• in longitudinal lies, the presenting part is fetal head or the breech, creating
cephalic and breech presentations.
• When the fetus lies with the long axis transversely, the shoulder is the
presenting part
FETAL POSITION

• Refer to the relation of the land mark on the presenting fetal part to the Ant. ,
Post. , or side left or right of the maternal pelvic
CARDINAL MOVEMENT OF LABOR

• 1 - engagement
• 2- descent
• 3- flexion
• 4- internal rotation
• 5- extension
FETAL PRESENTATION
FETAL ATTITUDE

• The head is sharply flexed; the chin is almost in contact with the chest; the
thighs are flexed over the abdomen; and the legs are bent at the knees.
CEPHALIC PRESENTATION

• On vaginal examination : Sagittarius suture , anterior & posterior Fontaine’s all

in same level
• the head is flexed sharply so that the chin contacts the thorax. The occipital
fontanel is the presenting part
CEPHALON PRESENTATION

• face presentation : fetal neck sharply extended so that the occiput and back
come into contact, and the face is foremost in the birth canal—.
• sinciput presentation: the neck is only partly flexed, the anterior (large)
fontanel may present.
• brow presentation: the neck is only partially extended, the brow may emerge
DIAMETER OF PRESENTATION IN VERTEX
PRESENTATION
DIAMETER OF PRESENTATION IN VERTEX
PRESENTATION
DIAMETER OF PRESENTATION IN VERTEX
PRESENTATION
OCCIPUT POSTERIOR PRESENTATION

• It is vertex presentation in which the occiput is placed posteriorly

• It can be
• 1) ROP : commonest
• 2) LOP :
• Suboccipio frontal diameter 10.5 cm
• 3) Direct OP
• Occipitofrontal diameter 11.5 cm
OCCIPUT
OCCIPUT POSTERIOR
POSTERIOR PRESENTATION
PRESENTATION

• Cause of OP :
• 1- affected 20 % of fetus at the beginning of labor
• 2- 50% of cases affected by anthropoid pelvic or android
• 3- Marked deflexion of fetal head
• 4- Abnormal uterine contraction
OCCIPUT POSTERIOR PRESENTATION

• Diagnosis :
• 1- from the history labor pain more in the back
• 2- on exam : lower uterine segment is empty
• 3- PV head not engaged and felt high
• What can cause :
• 1- prolong 2nd stage of labor
• 2- delivery face to pubic
• 3- difficult in instrumental delivery
BROW PRESENTATION

• rare presentation
• is diagnosed when that portion of the fetal head between the orbital ridge and
the anterior fontanel presents at the pelvic inlet
• Present Diameter is mento-vertex 13.5 cm
• In compatible with vaginal delivery
• more associated with premature fetus, multiple pregnancy
BROW PRESENTATION

• On vaginal examination
• Frontal suture , anterior font angels , orbital bridge , eyes and root of the nose
can be palpated
• Vaginal delivery cannot occur only by CS
BROW PRESENTATION

• Cause can be : android or platypelloid pelvic prematurity anencephaly ,

multiparty , tumoure in the neck , polyhydroamnios , umbilical cord around the
neck
• How to diagnosis?
• mostly diagnosis by vaginal delivery : Palpate supraorbital bridge , nose ,
anterior fontanel
• if the head high , observation , it my rotate to face or vertex , but if persist , to
CS
FACE PRESENTATION

• Head completely extension

• Submento - pregematic diameter 9.5 cm
• Slow progress due to lake of physiological moulding
• Most common Left mento anterior
• How to diagnosis?
• by vaginal delivery : orbital ridges , nose, mentum and gum , the fontanelles
and suture are not generally palpable
•
FACE PRESENTATION
FACE PRESENTATION

1st internal rotation from right or left

mento anterior to direct mento anterior
2nd flexion of the neck not extension
which occur in occipito anterior
except if the pelvic is abnormal or
there is tumour in the neck diameter
is presented is submento vertical
11.5 cm which might cause 3rd or 4th
perineal tear
•

• Rt or Lt mento posterior 20 - 30% rotate to mento anterior and deliver face to pubic
COMPOUND FETAL PRESENTATION

• The majority of compound presentations consist of a fetal hand or arm

• presenting with the head
• Incidence:1 in 250 to 1 in 1500 deliveries
• The head of the first twin and an extremity of the second twin present together
within the birth canal
COMPOUND FETAL PRESENTATION
MANAGEMENT

If noted on ultrasound examination following ECV it will resolve spontaneously.

In this setting,if a foot or hand is preventing the head from settling into the inlet,vibroacoustic
stimulation useful in prompting fetal movement
If a compound presentation is identified on ultrasound in patient with polyhydramnios
The patient should be councilled on the risks of a prolapsed umbilical cord and fetal extremity when membranes rupture.

For patients with normally progressing labor, either observation alone. Or attempting to gently reposition the fetal extremity.

A compound presentation involving the arm is more likely to resolve than one involving t foot

gently pushes the small part up into the uterine cavity with his dominant hand while simultaneously applying gentle fundal pressure to effect descent of the head
with the other hand. If this gentle maneuver does not resolve the compound presentation and abnormal progress of labor, proceeding to cesarean birth.
TRANSVERSE LIE
• DorsoAnterior -60%
• cause :
• 1) abdominal wall relaxation from high parity
• 2) preterm fetus
• 3) placenta previa
• 4) abnormal uterine anatomy
• 5) hydramnios
• 6) contracted pelvis.
• Women with four or more deliveries have a tenfold incidence of transverse lie
TRANSVERSE LIE

• Diagnosis :
• By the history : patient can till that feeling discomfort due to head located in
the right or left flank
• Examination : Abdominal palpation by Leopold’s maneuvers
• Confirm by ultrasound
TRANSVERSE LIE

Transverse lie, intact membranes, live fetus , external version (ECV) to cephalic presentation at approximately 37 weeks of gestation

• If repeat ECV is unsuccessful, then cesarean birth is performed at 39+0 to 39+6 weeks.

• If ECV is successful induction of labor , To do AROM, the procedure should be performed in a delivery room by puncturing the membranes with a long 20 gauge needle
Caesarean section in transverse lie

Do ECV after the anaesthesia before the CS

For the dorsosuperior (back up) & Dorsoposterior perform a low transverse uterine incision and extract the fetus as a footling breech.

• For the dorsoinferior (back down) Dorsoanterior perform an

intraabdominal version to convert the transverse lie to a breech presentation before making the hysterotomy, membranes are intact. perform a low transverse uterine incision and extract the fetus as a footling breech.

Preterm transverse lie a low transverse uterine incision extend to J shape or do low
vertical incision or inverted T

Complication

Cord prolapse hand prolapse Obstructed labor Fetal death Rupture uterus
BREECH PRESENTATION

• The incidence of breech presentation drops with gestational age and

approximates 3 percent at term. When the fetus presents breech, the three
general configurations are frank, complete, and footling presentations
BREECH PRESENTATION

• How to diagnosis : during cervical examination with a frank breech, no feet are
appreciated, but the fetal ischial tuberosities, sacrum, and anus are usually
palpable
BREECH PRESENTATION