MALPRESENTATION
Dr. S.K.S
 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.
Position
 Left mento-anterior- commonest
 Right mento-anterior
 Left mento-posterior
 Right mento-posterior
 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
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:-
Mento anterior
Mento posterior
Lateral grip
1. Fetal limbs are felt
anteriorly.
2. Back is on the flank &
is difficult to palpate.
3. The chest is thrown
anteriorly against the
uterine wall & is often
mistaken for back.
1. Back is felt to the front
and better palpated only
towards the podalic pole
because of extension of
spine.
Pelvic grip
1. Head seems big & not 1. Same
engaged.
2. Same
2. Sinciput is to the side 3. The groove is
towards the back lies.
prominent.
3. Groove between the
head and back is not
so prominent.
auscultation
1. FHS is distinctly
audible anteriorly
through the chest wall of
the fetus.
1. FHS is not so distinct
and is audible on the
flank.
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.
 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.
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.
 Second stage:Face presentation
.
Mento-anterior
Mento-posterior
90% case normal
spontaneous vaginal (face
to pubis) delivery with
liberal episiotomy
If delay forceps
delivery
LSCS
Dead fetus
Craniotomy
 Third stage:-
Active management.
Complications:Maternal :Prolonged labour
High operative interference.
Fetus:1. cong. Malformation.
2. Hypoxia
3. Operative delivery
4. Laryngeal oedema.
 Cause of delayed engagement in face
presentation:1. long diameter i.e. sub mento-vertical.
2. No moulding.
3. Weak uterine contraction.
 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
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
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
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