6/23/2022
• Malpositions and malpresentations present the midwife
with challenges of recognition and diagnosis both in
the antenatal period and during labour.
MALPOSITIONS OF THE OCCIPUT AND
MALPRESENTATIONS
• The midwife must ensure all examinations and
discussions with the woman are documented and
appropriate obstetric referral is made where a
malpresentation or malposition has been found.
• The midwife should take time to discuss this with
R. NDERITU
the women to ensure they understand what may
happen and the activities that may help (Munro and
Jokinen 2012).
The presenting diameters do not fit well onto the cervix and • In labour women should be encouraged to
therefore do not produce optimal stimulation for uterine
• adopt postures and positions they find comfortable and
contractions and labour.
• encouraged to remain mobile.
Labour with a fetus in a malposition or a malpresentation can
be long, tedious and painful, requiring empathy, sustained • They should be supported to use coping methods to deal
encouragement and support for the woman and her partner. with their particular pattern of labour (Simkin 2010).
All the usual care in labour is provided, paying particular • The progress of labour may be slow so midwives should
attention to comfort and hydration . take care to avoid the use of language that may
The woman should be encouraged to take an active part in demoralize the woman and her partner.
decisionmaking and must be kept informed throughout. • Any sign of fetal or maternal distress or delay in
labour must be referred promptly to an obstetrician.
1
, 6/23/2022
OCCIPITOPOSTERIOR POSITIONS
Practices that are considered unhelpful include • Occipitoposterior (OP) positions are the most
common type of malposition of the occiput
immobility and labouring on a bed, and occur in approximately 10–30% of labours,
the setting of arbitrary time limits on the various but only around 5% of births (Pearl et al
stages of labour and the 1993; Ponkey et al 2003; Munro and Jokinen
early use of epidural analgesia (Munro and Jokinen 2012).
2012).
• Women can be reassured that internal rotation
to anterior positions can be expected in the
majority of cases.
CAUSES
• A persistent OP position results from a failure of The direct cause of the occipitoposterior position is
internal rotation or malrotation prior to birth often unknown, but it may be associated with an
(Gardberg et al 1998; Peregrine et al 2007). abnormally shaped pelvis - In an android pelvis, the forepelvis
is narrow and the occiput tends to occupy the roomier
• The vertex is presenting, but the occiput lies in
hindpelvis.
the posterior rather than the anterior part of the
The oval shape of the anthropoid pelvis, with its narrow
pelvis. transverse diameter, favours a direct OP position.
• As a consequence, the fetal head is deflexed
and larger diameters of the fetal skull present
2
, 6/23/2022
ANTENATAL DIAGNOSIS
• Abdominalexamination On palpation While the breech is easily palpated at the
• Listen to the woman, as she may complain of fundus, the back is difficult to palpate as it is
backache and report feeling that her baby’s bottom well out to the maternal side, sometimes almost
is very high up against her ribs, as well as adjacent to the maternal spine.
feeling movements across both sides of her
Limbs can be felt on both sides of the midline.
abdomen.
The head is unusually high in an OP position which
• On inspection :
• There is a saucer-shaped depression at or just is the most common cause of non-engagement in a
below the umbilicus. This depression is created by primigravida at term.
the ‘dip’ between the head and the lower limbs of
the fetus. The outline created by the high, unengaged
head can look like a full bladdeR
•
This is because the large presenting diameter, the
occipitofrontal (11.5 cm), is unlikely to enter the
pelvic brim until labour begins and flexion occurs.
The occiput and sinciput are on the same level.
• Antenatal preparation
Flexion allows the engagement of the suboccipitofrontal
diameter (10 cm). • Research has shown that the woman adopting a
The cause of the deflexion is a straightening of the knee–chest position several times a day may
fetal spine against the lumbar curve of the maternal achieve temporary rotation of the fetus to an
spine. anterior position but has only a short-term effect
This makes the fetus straighten its neck and adopt upon fetal presentation (Kariminia et al 2004; Hunter
a more erect attitude. et al 2007).
On auscultation The fetal back is not well flexed so
the chest is thrust forward, therefore the fetal heart
can be heard in the midline. • For customary antenatal assessment of fetal position
However, the fetal heart may be heard more easily at Leopold’s manoeuvres can be used during abdominal
the flank on the same side as the back. examination.
3
• Malpositions and malpresentations present the midwife
with challenges of recognition and diagnosis both in
the antenatal period and during labour.
MALPOSITIONS OF THE OCCIPUT AND
MALPRESENTATIONS
• The midwife must ensure all examinations and
discussions with the woman are documented and
appropriate obstetric referral is made where a
malpresentation or malposition has been found.
• The midwife should take time to discuss this with
R. NDERITU
the women to ensure they understand what may
happen and the activities that may help (Munro and
Jokinen 2012).
The presenting diameters do not fit well onto the cervix and • In labour women should be encouraged to
therefore do not produce optimal stimulation for uterine
• adopt postures and positions they find comfortable and
contractions and labour.
• encouraged to remain mobile.
Labour with a fetus in a malposition or a malpresentation can
be long, tedious and painful, requiring empathy, sustained • They should be supported to use coping methods to deal
encouragement and support for the woman and her partner. with their particular pattern of labour (Simkin 2010).
All the usual care in labour is provided, paying particular • The progress of labour may be slow so midwives should
attention to comfort and hydration . take care to avoid the use of language that may
The woman should be encouraged to take an active part in demoralize the woman and her partner.
decisionmaking and must be kept informed throughout. • Any sign of fetal or maternal distress or delay in
labour must be referred promptly to an obstetrician.
1
, 6/23/2022
OCCIPITOPOSTERIOR POSITIONS
Practices that are considered unhelpful include • Occipitoposterior (OP) positions are the most
common type of malposition of the occiput
immobility and labouring on a bed, and occur in approximately 10–30% of labours,
the setting of arbitrary time limits on the various but only around 5% of births (Pearl et al
stages of labour and the 1993; Ponkey et al 2003; Munro and Jokinen
early use of epidural analgesia (Munro and Jokinen 2012).
2012).
• Women can be reassured that internal rotation
to anterior positions can be expected in the
majority of cases.
CAUSES
• A persistent OP position results from a failure of The direct cause of the occipitoposterior position is
internal rotation or malrotation prior to birth often unknown, but it may be associated with an
(Gardberg et al 1998; Peregrine et al 2007). abnormally shaped pelvis - In an android pelvis, the forepelvis
is narrow and the occiput tends to occupy the roomier
• The vertex is presenting, but the occiput lies in
hindpelvis.
the posterior rather than the anterior part of the
The oval shape of the anthropoid pelvis, with its narrow
pelvis. transverse diameter, favours a direct OP position.
• As a consequence, the fetal head is deflexed
and larger diameters of the fetal skull present
2
, 6/23/2022
ANTENATAL DIAGNOSIS
• Abdominalexamination On palpation While the breech is easily palpated at the
• Listen to the woman, as she may complain of fundus, the back is difficult to palpate as it is
backache and report feeling that her baby’s bottom well out to the maternal side, sometimes almost
is very high up against her ribs, as well as adjacent to the maternal spine.
feeling movements across both sides of her
Limbs can be felt on both sides of the midline.
abdomen.
The head is unusually high in an OP position which
• On inspection :
• There is a saucer-shaped depression at or just is the most common cause of non-engagement in a
below the umbilicus. This depression is created by primigravida at term.
the ‘dip’ between the head and the lower limbs of
the fetus. The outline created by the high, unengaged
head can look like a full bladdeR
•
This is because the large presenting diameter, the
occipitofrontal (11.5 cm), is unlikely to enter the
pelvic brim until labour begins and flexion occurs.
The occiput and sinciput are on the same level.
• Antenatal preparation
Flexion allows the engagement of the suboccipitofrontal
diameter (10 cm). • Research has shown that the woman adopting a
The cause of the deflexion is a straightening of the knee–chest position several times a day may
fetal spine against the lumbar curve of the maternal achieve temporary rotation of the fetus to an
spine. anterior position but has only a short-term effect
This makes the fetus straighten its neck and adopt upon fetal presentation (Kariminia et al 2004; Hunter
a more erect attitude. et al 2007).
On auscultation The fetal back is not well flexed so
the chest is thrust forward, therefore the fetal heart
can be heard in the midline. • For customary antenatal assessment of fetal position
However, the fetal heart may be heard more easily at Leopold’s manoeuvres can be used during abdominal
the flank on the same side as the back. examination.
3
