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Types of Mal-Presentation

Types of Mal-Presentation

Types of Mal-Presentation

QUESTION
Prepare the chart on types of Mal-Presentation. Assignment can include the following

Introduction
Objectives
Definition
Types with pictures
General nursing care during Intra-natal
References
Note: Can be submitted in PDF form and can be written up to 3-4 pages.
Types of Mal-Presentation

ANSWER
Types of Mal-Presentation

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During pregnancy, the baby moves actively but the baby’s position towards labor is crucial as it determines how easy or complicated the delivery will go. Most normal pregnancies always have the babies entering the pelvic area headfirst and where their chin is tucked to their chest, but on other occasions, this does not happen (Sharshiner & Silver, 2015). The problem is that the baby is in a wrong position, an occurrence that most health professionals refer to as malpresentation. Malpresentation presents a challenging clinical position, even for the most experienced caregivers. This presentation aims to enlighten about abnormal presentations, their diagnostic criteria, cause and complications, and general nursing care to prevent the development of compilations.
Objectives
This presentation aims to enlighten about abnormal presentations, their diagnostic criteria, and general nursing care to prevent the development of compilations. The paper will also define some key terms used in obstetric care. Another objective is to understand the causes and complications for the mother and the fetus during labor due to malpresentation. The presentation will also recommend when and how to refer a mother in labor caused by malpresentation. The last objective is to provide a recommendation of general nursing practice during Intra-natal care.
Definitions
Presentation: The term refers to the region of the fetus’s body that is first to proceed into the birth canal or the pelvic inlet (Sharshiner & Silver, 2015).
Position: This refers to how the fetus is either facing forward (face up) or rearward (that is, facing the mother’s back or face down when the mother lies on her back).
Fetal vertex: This defines the area between the posterior fontanel and the anterior fontanel.
Vertex presentation: This occurs when the fetal vertex is the presenting part. The crown of the baby’s head is against the cervix and the face in a rearward position. This position can also be referred to as a cephalic presentation (Sharshiner & Silver, 2015).
Within the first 28 weeks of pregnancy, the fetus size is usually small in relation to the intrauterine volume; thus, it can move and rotate from breech to cephalic presentation and back without much complexities or causing complications (Sharshiner & Silver, 2015). As time goes, the fetus develops in size and weight and assumes the cephalic presentation to accommodate the fetus size in the more spacious fundal portion of the uterus as labor approaches. The vertex, which is the top of the fetal head, is always at the mother’s pelvic brim with the chin tucked in the chest, thus in a position entering the mother’s pelvis for a normal birth as shown below.

Types of Malpresentation
There are several types of malpresentation, and the most common include breech presentation, abnormal lie, occiput posterior position, brow, and face presentation.
Breech presentation
The common types of breech presentations are Frank breech, complete, and incomplete breech, as shown.

Breech presentation is mostly characterized by a fetus whose buttocks or feet are presenting as in the case of a footling breech (Sharshiner & Silver, 2015). Before going to labor, the caregiver may try to adjust the position being guided by ultrasound imaging. If that does not work, a cesarean section is done since vaginal delivery may not be possible as it places a lot of risks on the baby’s life, including injuries. Circumstances that may lead to breech include preterm labor, birth defects of the fetus, and abnormal shape of uterus or growths.

Oblique and Transverse lie.

Transverse and oblique lie mostly occur when the fetus is in a position where the shoulder is the significant part that is presenting. These types of presentations affect nearly 0.03% of deliveries (Pilliod & Caughey, 2017). Diagnosis is made through ultrasound examination and Leopold Maneuver. The reason for this type of malpresentation is the development of a small fetus, prematurity, or due to high parity, the uterus is deformed. An external cephalic version can be used to remedy the situation before labor and rupture of the membrane, but if they occur, the advisable approach is to perform a cesarean delivery. A case of transverse or oblique presentation in the second child in twins delivery does not require partaking a cesarean delivery, but the fetus can be manually turned and delivered normally through the vagina.

Face and Brow Presentation

Face and brow presentations happen when the baby is cephalic presenting, but instead of having the chin embedded onto the chest, the neck is extended so that the vertex is not presenting as it should. Both brow and face presentations are uncommon and only occur in 0.1-0.2 % of all deliveries (Pilliod & Caughey, 2017). The risk factors to face and brow presentations are prematurity, black ethnicity/ race, nulliparity, fetal growth disorders, and fetal anomalies. Diagnosis for these abnormal events can be through ultrasound of palpation for facial parts. With a brow presentation, the chin is not palpable, but it can be felt with a face presentation. Vaginal delivery in the face presentation may require the caregivers to extend the fetus neck beyond what is physiologically possible, thus being dangerous for the fetus. Suppose spontaneous flexion or rotation fails to occur. In that case, cesarean delivery may be considered since manual assistance has it considered risks such as cord prolapsed, uterine rupture, and spinal trauma on the baby.
Occiput Posterior Position (Sunny Side Up)

This form of malpresentation occurs when the baby has his/her head on the down position but the face or chin and nose facing the mother’s front (upward) rather than her back. The labor forces can successfully rotate the baby, but some never rotate and are delivered while facing upwards (Pilliod & Caughey, 2017). The problem with this kind of delivery is that the mother will experience slow labor, more back pain, and more time pushing than when the baby is facing the back.
Compound presentation
Compound presentation occurs when the fetus presents with an extremity, a leg or arm, adjacent to the head, as shown in the figure below. This is not a common occurrence, but it affects nearly 0.1-0.2% of deliveries. The common cause of compound presentation includes multiple gestations, high amniotic fluids levels, prematurity, and low birth weight (Pilliod & Caughey, 2017). Management of the protruding fetal part can be retracted when the head approaches the pelvis if the compound presentation is diagnosed early or gentle reduction with upward pressure on the extra approaching organ can be attempted. In case of a situation where the extremities cannot move, cesarean delivery should be the option to avoid causing fetal injuries.

General nursing practice during Intra-natal care
Intra natal care is important for both maternal and perinatal health. Nurses need to harness their skills and knowledge which are much needed for the survival of the child and mother. The work of the nurse begins from admission assessment where after taking typical biography data the nurses enquires for information on estimated date of birth, characteristics of contractions, fetal movements, parity, history of previous labors, membrane status, and appearance of any vaginal bloody show. The nurse can then progress to take a physical examination of the mother’s body systems and vitals such as blood pressure, temperature, respiration, measurement of height and weight, hydration status, respiration, lung sound, auscultation of the heart, and pain. Assessment during labor is a continuous process to check the vitals. All through the nurse should brief the mother of the process and expectations while also encouraging her to be comfortable, and maintain her physical and psychological composure. Most importantly the nurse should observe the mother’s emotions, body language and posture, support structure, energy levels, support system, and perceptual acuity.
While in some other settings it is the work of the physician or midwives to make a vaginal assessment of laboring mother, nurses in community hospital do so because most of the time physicians are not within labor and birth suites. The purpose of making a vaginal examination is to assess signs of true labor, cervical dilation, fetal membrane status, percentage of cervical effacement, and also collect information on presentation, station, position, molding or presence of fetal skull, and degree of fetal head flexion. The nurse can then assess uterine contractions which can be monitored electronically or through palpations to review its intensity, frequency, resting tone, and duration. The nurses can also use Leopold’s maneuvers to determine the baby’s presentation, lie, and position. With all the data collected and accurate diagnosis done, the nurses should use the data to develop a care plan for the mother to help her through labor and birth. A smooth transition during labor assures a great chance of healthy and safe delivery. To avoid harm to the mother and fetus, caregivers should adhere to evidence-based practice, and if by any case a clinical choice presents, always chose the mother’s safety.
Malpresentation are not common since, in most cases, they may present in 1 out of 25 pregnancies. Most of the cases are diagnosed through palpations or ultrasound. Malpresentation can be corrected from the 36th week of pregnancy, where an obstetrician can gently turn the baby or use the external cephalic version technique. While some complications may allow vaginal birth, they should only be done in a care institution (Pilliod & Caughey, 2017). The only risks involved with malpresentation include a cesarean or assisted delivery. Caregivers need to monitor a pregnant mother closely, and with every visit, they ensure that accurate identification of fetal presentation is taken to offer appropriate management. Continued research, education, and caregivers’ training are critical to ensure that they provide personalized care to mothers and neonates.

References
Pilliod, R. A., & Caughey, A. B. (2017). Fetal malpresentation and malposition: diagnosis and management. Obstetrics and Gynecology Clinics, 44(4), 631-643.
Sharshiner, R., & Silver, R. M. (2015). Management of fetal malpresentation. Clinical obstetrics and gynecology, 58(2), 246-255.

Types of Mal-Presentation

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