Malpresentation Complete Obstetric Reference

Below is your **complete, concise-but-fully-detailed medical reference on *Malpresentation*** following your preferred pattern (definition → pathophysiology → causes → types → clinical features → investigations → differential diagnoses → management → drug details → counseling).

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# ⚠️ **Malpresentation — Complete Obstetric Reference**

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## ✅ **1. Definition**

**Malpresentation** refers to any fetal presentation **other than vertex (occiput)** after 36 weeks or during labour.
Includes: **breech**, **transverse lie**, **oblique lie**, **face**, **brow**, and **compound presentation**.

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## ✅ **2. Pathophysiology**

Malpresentation occurs when:

* The **longitudinal axis** of fetus ≠ maternal axis OR
* The **presenting part** ≠ flexed occiput.

Factors:

* Reduced space, abnormal shape → fetus cannot engage.
* Excess space → fetus remains mobile (multiparity, polyhydramnios).
* Mechanical barriers (fibroids, placenta praevia).

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## ✅ **3. Causes / Risk Factors**

### **Maternal factors**

* Contracted pelvis
* Uterine anomalies (bicornuate, septate)
* Uterine fibroid
* Placenta praevia (especially transverse lie)
* Grand multiparity
* Polyhydramnios / Oligohydramnios
* Previous C-section

### **Fetal factors**

* Prematurity
* Multiple pregnancy
* Fetal anomalies (anencephaly, hydrocephalus)
* IUGR
* Short cord

### **Placental factors**

* Placenta praevia
* Fundal placenta causing breech

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## ✅ **4. Types**

### **A. Breech Presentation**

* *Frank breech* — hips flexed, knees extended (most common)
* *Complete breech* — hips & knees flexed
* *Footling breech* — feet below buttocks
* *Kneeling breech*

### **B. Transverse Lie**

* Fetal spine perpendicular to maternal spine
* Shoulder presentation

### **C. Oblique Lie**

* Fetal long axis oblique

### **D. Face Presentation**

* Hyperextended head → mentum (chin) presents

### **E. Brow Presentation**

* Partially extended head → bitemporal diameter

### **F. Compound Presentation**

* Limb + head presenting simultaneously

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## ✅ **5. Clinical Features**

### **Symptoms/Signs**

* Irregular abdominal shape
* High, unengaged presenting part
* Palpation:

* Breech: soft irregular mass in lower pole
* Transverse: empty pelvic inlet
* Vaginal exam:

* Breech: soft buttocks, cleft, genitalia
* Shoulder: acromion, axilla, ribs
* Face: mouth, nose, orbital ridges
* Brow: supraorbital ridge

### **In labour**

* Prolonged labour
* Cord prolapse risk increases (especially footling, transverse)

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## ✅ **6. Investigations / Diagnosis**

### **Clinical Examination**

* Leopold’s maneuvers
* Pelvic exam

### **Ultrasound (Gold standard)**

* Presentation
* Position
* Flexion/extension
* Placenta location
* Amniotic fluid
* Fetal anomalies

### **Others**

* NST / CTG for fetal wellbeing

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## ✅ **7. Differential Diagnoses**

* Fetal anomaly mimicking presenting part
* Ballotable but cephalic head (not malpresentation)
* Unstable lie
* Obstructed labour
* Contracted pelvis

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## ✅ **8. Management (Complete & Stepwise)**

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### **A. Breech Presentation**

#### **A1. Antenatal (≥36 weeks)**

* **Offer ECV (External Cephalic Version)** at 36–37 weeks
Contraindications:

* Placenta praevia
* Oligohydramnios
* Multiple pregnancy
* Uterine anomalies
* Previous classical CS
* Any contraindication to vaginal delivery

#### **A2. In Labour**

**Options:**

1. **Planned Vaginal Breech Delivery (select cases)**

* Frank/complete breech
* ≥37 weeks
* No fetal compromise
* Adequate pelvis
* Experienced obstetrician

2. **Cesarean section**
Indications:

* Footling breech
* Primigravida
* Macrosomia
* Prematurity (<32–34 w)
* Hyperextended neck

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### **B. Transverse Lie / Shoulder Presentation**

* **Always deliver by cesarean section** unless:

* Second twin → internal podalic version possible
* Very high risk of:

* Cord prolapse
* Uterine rupture

**NO vaginal delivery for transverse lie.**

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### **C. Oblique Lie**

* Unstable lie → Manage expectantly but admit after 37 weeks
* If stabilizes to transverse → CS
* If converts to cephalic → allow labour

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### **D. Face Presentation**

* **Mentum anterior (MA)** → Vaginal delivery possible
* **Mentum posterior (MP)** → *Never* deliver vaginally → **Cesarean**
* Brow → almost always converts to face/vertex or requires CS

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### **E. Compound Presentation**

* Usually resolves spontaneously
* Avoid traction
* If limb prolapses → **Cesarean section**

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## ✅ **9. Drugs in Management (For Breech ECV)**

### **1. Tocolytic – Terbutaline**

| Parameter | Details |
| --------------------- | --------------------------------- |
| **Indication** | Facilitate ECV |
| **Mechanism** | β2-mediated uterine relaxation |
| **Dose** | 0.25 mg SC 15–20 min before ECV |
| **Pharmacokinetics** | Onset 5–15 min, duration 1–1.5 h |
| **Common AEs** | Tremor, palpitations, tachycardia |
| **Serious AEs** | Pulmonary edema (rare) |
| **Contraindications** | Cardiac disease, hyperthyroidism |
| **Interactions** | MAOIs ↑ toxicity |
| **Monitoring** | FHR, maternal pulse |
| **Counseling** | May feel palpitations; temporary |

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## ✅ **10. Complications**

### **Maternal**

* Obstructed labour
* Uterine rupture
* PPH
* Birth canal trauma

### **Fetal**

* Cord prolapse
* Asphyxia
* Birth injuries (especially breech)
* Prematurity complications

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## ✅ **11. Patient Counseling Points**

* Movement to cephalic presentation may occur until 36 weeks
* Regular fetal movement checks
* Come immediately if:

* Waters break
* Bleeding
* Reduced fetal movement
* Discuss pros/cons of ECV
* Delivery may require C-section depending on presentation

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