Birth Emergency Skills Training Malpresentations

Written and Illustrated by Bonnie U. Gruenberg, CNM, MSN, CRNP, EMT-P

The advice and strategies presented herein are not intended for use by nonprofessionals, may not be appropriate for every situation, and should not be used outside the applicable protocol or scope of practice. Neither the author nor the publisher shall have any liability to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by the information presented.

Malpresentations

• Vertex presentation is associated with the best outcomes.

• Malpresentations may be long-standing or occur suddenly.

Compound presentation• Hand

presents alongside the head.

• Gently pinch the fetal fingers, and he may pull the hand back.

Face presentation• Face presents first --

most extreme version of deflexion.

• Face may be swollen and bruised.

– Facial swelling may create airway problems for the newborn

Face Presentation

• Delivery is not necessarily more difficult - head diameters are about the same as vertex.

• Mentum posterior deemed “undeliverable “ by most authorities- but successful mentum posterior deliveries do occur.

Occiput Posterior (OP)

• Fetal back towards maternal spine.

Associated with– Increased risk for Cesarean.– Fetal acidemia.– Meconium stained fluid.– Birth trauma, 5-min Apgar

score less than 7 and admission to NICU.

– Perineal and periurethral lacerations are more common.

Occiput Posterior (OP)

• Slower progress and less effective contractions.

• Persistent anterior lip or cervical edema is common.

• Deflexion creates relative cephalopelvic disproportion. – Occiput drops into hollow of

sacrum and extends head

Fetus in right occipito-posterior position

(ROP)

Direct occiput posterior.

Shoulder or Transverse Presentation

• Fetus lies sideways across the uterus.

• Arm may hang out of the vagina.

• Cord may prolapse.

A live fetus in transverse presentation is not deliverable vaginally

Shoulder or Transverse Presentation

• Rapid transport to the hospital is essential.

• Put mother in knee-chest position.

• Give high-flow oxygen.• Administer IV crystalloid

solution.

A shoulder presentation with a live fetus is not deliverable vaginally.

Breech

• Buttocks or feet at the cervix.

• 3–4% of full term labors.

Footling breech.

Breech

Risk factors• Premature delivery.• Grand multiparity.• Polyhydramnios.• Oligohydramnios.• Certain fetal or uterine

anomalies.• Multiple Gestation.• Placenta previa.

Breech Presentations

Frank breech• Buttocks enter the pelvis, with

hips flexed and legs extended.• Most favorable for a vaginal

delivery.Complete breech• Fetus squatting or sitting cross-

legged on the cervix.Footling breech• One or both feet are presenting.

The sacrum of the frank-breech fetus is the part that presents to the maternal pelvis.

Risks of Breech Delivery

• Head may become entrapped after body is born.

• Cord may prolapse or compress.

• Infant may suffer birth trauma.• Placenta may detach after body

delivers.• Sometimes breech baby is born

rapidly and unexpectedly.

Breech Delivery (Frank Breech Presentation)

• Hands off the breech!• Frank breech usually delivers with

one hip toward the pubic bone.• First anterior hip delivers, then

posterior hip with lateral flexion.• Body emerges to umbilicus.• Mothers effort delivers baby.• Back should then face up; May

gently guide infant to this position.

The frank breech fetus usually delivers with one hip toward the pubic bone and the other toward the mother’s sacrum.

Breech Delivery (Frank Breech Presentation)

• Feet should spring free as body descends.

• Gently sweep arms across chest and out if necessary.

• Wrap emerging infant in a warm towel or blanket.

• Do not attempt to pull the baby out.

• To deliver the head, lift the fetal body slightly upwards.

Eventually, the feet should spring free as the body descends.

Wrap the body in a warm blanket.

Breech Delivery

If head does not deliver• Rapid transport is critical.• Insert hand into vagina and make an

airway for the baby.• Supply blowby oxygen to baby and high

flow to mother.• Avoid handling cord.• Keep fetal body wrapped in dry warm

towels.• Establish intravenous access in the

mother.• While mother pushes, lift fetal body

without hyperextending neck, and have an assistant apply suprapubic pressure.

Methods of Last ResortBreech Head Entrapment

• Dührssen incisions are sometimes made in the cervix at the 2 o’clock or 10-o'clock position to facilitate delivery of fetal head if cervix incompletely dilated.

• Zavanelli maneuver can replace the fetus into the uterus to be delivered by cesarean.

Babies will maintain the frank breech position after birth,an may have hip dysplasia.

The advice and strategies presented herein are not intended for use by nonprofessionals, may not be appropriate for every situation, and should not be used outside the applicable protocol or scope of practice. Neither the author nor the publisher shall have any liability to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by the information presented.

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