OG14.3 | Malpresentation and Malposition — Summary & Reflection

KEY TAKEAWAYS

Malpresentation encompasses any presentation other than vertex: breech (frank, complete, footling — in decreasing frequency), face, brow, transverse/shoulder lie, and compound presentation. Malposition refers to an abnormal vertex position — occipitoposterior being the most common. Diagnosis is by Leopold's manoeuvres and vaginal examination, confirmed by ultrasound. Management principles: breech at term should be offered ECV from 36–37 weeks (success ~50–60%); ECV is absolutely contraindicated with placenta praevia, APH, fetal compromise, or ruptured membranes. Failed ECV or declining ECV leads to elective CS (most settings) or assisted vaginal breech (experienced team, frank/complete breech, adequate pelvis). Face presentation: mentum anterior = vaginal delivery possible; mentum posterior = CS mandatory. Brow = almost always CS. Transverse lie = CS (or ECV if very early labour). Occipitoposterior: most rotate spontaneously; manage with position change, analgesia, and patience; persistent OP in the second stage may require rotational instrumental delivery or CS. Cord prolapse is the main emergency with footling breech and transverse lie — immediate CS if it occurs.

REFLECT

Reflect on a scenario where a woman comes to the labour ward at 38 weeks with a breech presentation not detected antenatally. ECV is now less likely to succeed (membranes may be ruptured, she may already be in early labour). What antenatal systems should have detected this earlier? How would you counsel her at this stage about her options — CS versus vaginal breech delivery? What factors would influence your recommendation? Now think more broadly: in a district hospital without an experienced operator for assisted breech delivery, what is the role of clinical protocols and team training in ensuring safe outcomes for malpresentation?