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G. Malpresentation 2005 ALSO® Syllabus Update G: Malpresentations, Malpositions, and Multiple Gestations Evidence Review completed: October 18, 2005 By Allan Wilke, MD and Harry (Chip) Taylor, MD, MPH Update published: December 6, 2005 SORT A Recommendation • Planned cesarean birth reduces perinatal mortality, neonatal mortality, and serious neonatal morbidity compared to planned vaginal breech delivery. SORT B Recommendation • Planned cesarean birth does not reduce the risk of death or neurodevelopmental delay in children at 2 year follow-up compared to planned vaginal breech delivery. A Cochrane Review1 of 3 RCTs with a total of 2396 breech deliveries found that planned cesarean birth (PCB) led to a reduction in perinatal/neonatal morbidity and mortality when compared to planned vaginal birth (PVB). PCB was associated with a corresponding increase in short-term maternal morbidity. (See table below). The Term Breech Trial2 was the largest of the 3 RCTs and drove the conclusions of the Review. It was the only RCT with long term follow-up; 920 infants and 917 mothers were evaluated 2 years after breech birth. The infant outcomes (death or neurodevelopmental delay) were similar in PCB and PVB groups.3 Maternal outcomes in the two groups (including perineal pain, back pain, sexual problems, painful intercourse, incontinence, and others) were also similar.3 Outcomes # Events/Patients Relative Risk NNT/ (%) (95% Confidence NNH** PCB PVB Interval) Perinatal/neonatal death or severe 17/1039 52/1039 0.33 (0.19-0.56) 30 neonatal morbidity* (1.64%) (5.00%) Perinatal/neonatal death 3/1166 14/1222 0.29 (0.10-0.86) 112 (0.26%) (1.15%) Maternal morbidity (short-term) 107/1169 106/1227 1.29 (1.03-1.61) 196 (9.15%) (8.64%) Death or neurodevelopmental delay 14/457 13/463 1.09 (0.52-2.30) *** at age 2 years* (3.06%) (2.81%) * Combined outcome ** NNT is the number needed to treat; NNH is the number needed to harm. *** Since the 95% Confidence Interval includes 1.00, the result is not statistically significant and the NNH is not calculated. Fatal anomalies were excluded from the perinatal/neonatal death rates. The American College of Obstetrics and Gynecology (ACOG) issued an Opinion4 noting that reduction in risk from cesarean versus planned vaginal breech delivery is greatest in industrialized nations with low perinatal mortality rates. ACOG concludes that planned vaginal delivery of a singleton term breech may no longer be appropriate. 2005 ALSO® Syllabus Update G: Malpresentations, Malpositions, and Multiple Gestations ALSO® acknowledges the important implications of this new evidence and the recommendations of the ACOG Committee. ALSO® does not advocate routine vaginal delivery for breech presentation. However, the decision how best to deliver a breech presentation is complicated and may be based on consideration of many factors, including the patient’s informed consent. Because unanticipated breech vaginal deliveries do occur, obstetrical caregivers need to have the knowledge and skills to safely handle this situation. It is for this reason that ALSO® teaches a standard method to prepare ALSO® providers to manage a vaginal breech delivery. 1 Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery. The Cochrane Database of Systematic Reviews 2005, Issue 4. [Evidence level 1, systematic review of RCTs] 2 Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356(9239):1375-1383. [Evidence level 1, RCT] 3 Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at two years after planned cesarean section versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191:917-927. [Evidence level 2, prospective cohort study] 4 ACOG committee opinion: number 265, December 2001. Mode of term single breech delivery. Obstet Gynecol. 2001;98:1189-1190. [Evidence level 3, consensus guideline] G: Malpresentations, Malpositions, and Multiple Gestation (slide 1) Steven H. Eisinger, M.D. Objectives (slide 2) At the end of this lecture / discussion and workstation, participants will be able to: 1. Define six types of malpresentations and methods for diagnosis. 2. List complications associated with each malpresentation. 3. Discuss the criteria for allowing vaginal delivery, and the management of vaginal delivery, when appropriate. 4. Discuss multiple gestation, with special attention to labor and delivery. 5. Perform safe, effective delivery of various malpositions and malpresentations using the maternal-fetal mannequin. Definitions (slide 3) Definitions are important to a discussion of malpresentations. Lie refers to the relationship of the long axis of the fetus to that of the mother, specified as longitudinal, transverse, or oblique (also referred to as unstable). Presentation refers to the portion of the fetus that is foremost or “presenting” in the birth canal. The fetus may present by its vertex, breech, face, brow, or shoulder. Position refers to a reference point on the presenting part, and how it relates to the maternal pelvis. For example, the reference point on the vertex is the occiput. When the fetal occiput is directed toward the mother’s symphysis, or anteriorly, the fetus is in occiput anterior (OA) position. When the occiput is directed toward the maternal spine, the fetus is occiput posterior (OP). Intermediate positions around the compass are left and right occiput anterior (LOA and ROA), left and right occiput transverse (LOT and ROT), and left and right occiput posterior (LOP and ROP). Methods of Diagnosis (slide 4) There are three principal methods of determining fetal lie, presentation, and position. The first is Leopold’s maneuvers or abdominal palpation. The second method is vaginal exam. The third method is imaging. Ultrasound is the preferred imaging method. Labor floor ultrasound examination is widely utilized in hospitals G: Malpresentations, Malpositions, and Multiple Gestation 1 of all sizes, and every birth provider should have acquaintance with ultrasound skills in this setting to determine fetal lie, presentation, and position. Occasionally x-ray is necessary, particularly when fine detail is needed, such as the position of the limbs in a breech. Incidence of Malpresentations at Term1,2 Malpresentation Incidence Percent Occiput posterior 1 in 10 to 20 5 to 10 Breech 1 in 25 to 33 3 to 4 Transverse lie or shoulder presentation 1 in 322 to 420 0.3 to 0.23 Face 1 in 500 to 1200 0.2 to 0.08 Compound presentation 1 in 700 to 2235 0.14 to 0.047 Brow 1 in 4470 0.02 The Fetal Head and the Maternal Pelvis (slide 5) Most fetal malpresentations (posterior, breech, face, brow) are clinically significant because the fetal head is not round, but rather ovoid or egg-shaped. The smallest of the fetal diameters is the suboccipitobregmatic; the largest is the occipitomental. The difference between them is three centimeters, or about 24 percent. When the head is in full flexion, the suboccipitobregmatic or smallest diameter presents to the pelvis. When the head is in full extension (or deflexion) the occipitomental or largest diameter presents. Delivery is much more likely to occur, and will be easier, if a smaller diameter presents. Therefore, the attitude of the fetal head (flexion versus extension) as it presents to the pelvis is of paramount importance. A degree of fetal extension of the head occurs with OP presentations, face and brow presentations, and some breeches. (slide 6) Asynclitism also plays a major role in the mechanics of labor. Asynclitism is lateral flexion of the head, such that the sagittal suture is not in the middle of the birth canal. Some degree of asynclitism is normal, and the fetal head may even shift back and forth from anterior to posterior asynclitism as the head accommodates more deeply into the pelvis. Extreme degrees of asynclitism may prevent labor from progressing. Asynclitism becomes a major factor in adequate forceps application. G: Malpresentations, Malpositions, and Multiple Gestation 2 The maternal pelvis also plays an important role in the cause of various (slide 7) malpresentations and prognosis for delivery. There are four pure types of pelves. Most women have a gynecoid or intermediate type: • Gynecoid (round) • Anthropoid (oval, with the long axis in the AP plane) • Platypelloid (oval, with the long axis in the transverse plane) • Android (triangular or heart-shaped, with the apex of the triangle anteriorly) While a full discussion of pelvic types and pelvimetry is of limited clinical usefulness, it can be generalized that a narrow pelvis such as the anthropoid can cause persistent occiput posterior; the platypelloid pelvis can cause a transverse arrest; the android pelvis is prejudicial to delivery with all malpresentations; and an inadequate or small pelvis can be associated with most of the malpresentations, mainly based on the inability of the head to descend, engage, or rotate. Occiput Posterior Position In the Occiput Posterior (OP) position, the fetus lies with its occiput towards the mother’s spine and its face towards the mother’s symphysis and abdomen. In other words, the fetus is face up when the mother is supine or in lithotomy position. Usually the fetus in occiput posterior position will rotate spontaneously to occiput anterior (OA) and deliver spontaneously. Spontaneous rotation fails to occur in five to ten percent of cases, and the fetus remains in persistent occiput posterior position. The exact cause of persistent OP is unknown, but transverse narrowing of the pelvis plays a role. All occiput posterior fetuses are somewhat deflexed because the vertex drops back to fill the hollow of the sacrum. The combination of deflexion and posterior presentation causes less favorable diameters of the fetal head to present to the pelvis than when the fetus is in the occiput anterior position. (slide 8) The diagnosis of OP is based on observation of the patient and examination.
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