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Introduction:
In pregnancy, normal vaginal delivery is possible if the baby is in a favorable position. In clinical terms, it is called presentation. It refers to the anatomic part of the baby that first proceeds to the pelvic inlet or the birth canal. Any position other than the head down or head down with the head extended can be an unfavorable position for vaginal delivery.
What Is a Presentation in Pregnancy?
The term presentation refers to the position of the baby or how the baby is facing down in the birth canal. The ideal presentation is called vertex presentation, via the head first and the chin tucked into the baby's chest. This is the most favorable position for a vaginal delivery. The head of the baby coming first is the safest, and any other body parts coming down the birth canal make the vaginal delivery complex, and a cesarean is preferred. Any presentation other than the vertex is considered a malpresentation.
What Are the Factors Leading To Malpresentation?
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Women who had more than one pregnancy.
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More than one fetus in the uterus.
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Uterus with increased or decreased levels of amniotic fluid.
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The uterus is not in normal shape and has abnormal growths like fibroids.
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Placenta previa (the placenta is at the bottom of the uterus, near the cervix, where normal vaginal delivery is not possible).
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Preterm baby (a baby born too early is a preterm baby).
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Partial septate uterus (the septum extends partially into the uterus and dividing the uterus into two)
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Primiparity (refers to a woman who is bearing a child for the first time).
What Are the Various Types of Malpresentations?
Usually, malpresentation refers to fetal presentation parts other than the vertex. It is identified late during pregnancy or may remain undiscovered till the initial assessment of labor.
Types of Malpresentation includes:
Breech Presentation:
In breech presentation, the baby's feet or buttocks are the first body parts that will contact the cervix. Approximately 3 percent of childbirths are affected by fetal attitude. This presentation is difficult for birth, and the presenting point influences the degree of difficulty.
The maternal risks associated with beach malposition are
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Prolonged labor.
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Decreased pressure exerted by the breach on the cervix.
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C-section or forceps delivery.
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Trauma to the birth canal in forceps delivery.
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Intrapartum or postpartum hemorrhage.
The associated fetal risks are
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Compression of umbilical cord.
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Entrapment of the fetal head in the cervix.
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Aspiration and asphyxia during delivery.
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Trauma to fetal head in forceps delivery.
Due to the trauma and associated complications with forceps delivery, this technique is no longer practiced in child labor.
Frank Breech Presentation:
In this position, the baby's bottom comes first, legs flexed at the hip and extended at the knees, similar to the feet near the ears. About 70 percent of breech babies are in frank breech presentations.
Complete Breech Presentation:
In this, the baby's hip and knees are flexed, and the baby is sitting cross-legged with the feet beside the bottom.
Footling Presentation:
In this presentation, one or both feet come first, with the bottom at a higher position. This is a rare malpresentation but common with premature fetuses.
Kneeling Breech Presentation:
In this presentation, the baby is in a kneeling position with one or both legs extended at the hips and flexed at the knees. This is an extremely rare malpresentation.
Brow Presentation:
In a brow presentation, there is a partial extension of the fetal head where the occiput is higher than the sinciput. Sinciput is the front part of the head or skull and occiput is the back part of the head.
Face Presentation:
In this malpresentation, the fetal head is hyperextended, so the occiput or sinciput is not palpable on vaginal examination.
Sinciput Presentation:
In sinciput presentation, the fetal head portion with a larger diameter is presented. This causes slower descent of the fetal head, and labor progress is delayed.
Transverse Presentation:
In this presentation, the fetus is positioned with the head along one side of the pelvis and the buttocks on the other side and lying transversely. The fetal axis is perpendicular to that of the mother. In this position, vaginal delivery is impossible. The presenting part is usually one of the shoulders, hand, or elbow.
How to Manage Fetal Malpresentations?
Breech Presentation:
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If the pregnant woman is in early labor with an intact membrane, an External cephalic version is attempted.
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The external cephalic version is a procedure used to turn the baby from a breech position to a favorable head-down position. Hands are placed over the gravid abdomen, applying pressure and moving the fetus to the vertex position. If done successfully, a vaginal delivery is possible. No serious complications were reported.
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Vaginal breech delivery is assisted by a skilled health care provider is safe and feasible.
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There should be an adequate size of a woman's pelvis that make vaginal birth possible. The fetus should have a flexed head, and the fetus is not too large.
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Cesarean section is another way to manage the situation, and it is safer than vaginal breech delivery. It should be done if there is no possible way for successful vaginal breech delivery.
Chin Anterior Position:
In the chin anterior position, the labor is prolonged, and delivery of the head is done by flexion, where the head is bent forward towards the chest. If the cervix is fully dilated, proceed with a normal childbirth. If there is slow progress, give oxytocin to ease the labor.
In some cases, the cervix may not be fully dilated, but there are no signs of obstruction; the labor can be helped with oxytocin.
Chin Posterior Position:
In the chin posterior position, the head is fully extended and blocked by the sacral bone. This
prevents vaginal delivery. A cesarean section is done to deliver the baby.
Brow Presentation:
In brow presentation, deliver the baby by cesarean section. Do not attempt vacuum extraction, forceps delivery, or other methods.
Transverse Presentation:
If the baby is preterm and smaller in size, an attempt to turn the fetus may be made. Fetuses in transverse lie position are delivered through cesarean section.
Conclusion:
The position of the baby in the uterus and the presentation during labor are important in determining whether a vaginal delivery is possible or to move for an emergency cesarean section. Monitoring the health of the mother and baby is important in managing labor. If a woman has a malpresentation in one pregnancy, there is more chance for it to happen again.
