Malpresentations & Malpositions: Causes and What the Midwife Should Do

Malpresentations & Malpositions are among the causes of poor progress of labour. Good progress of labour is enhanced when the presenting part is well applied to the cervix.

In malpresentation like face presenting part is not well applied resulting to poor progress. Also, in face presentation the face is not compressible for a lesser diameter to pass through the pelvis, like moulding in the vault.

 Through vaginal delivery is possible but takes longer. Brow presentation is larger than diameters of pelvis, except hypertension of the neck occurs and face presentation result in.  Shoulder presentation cannot be delivered vaginally.

What are risk factors/causes of Malpresentations & Malpositions?

• High purity due to laxity of uterine muscles
• Abnormalities of uterus e.g., fibroid
• Septate uterus
• Oligohydramnios
• Placenta previa
• Pelvic abnormality
• Multiple gestation
• Fetal abnormality e.g., anencephaly

How abnormalities of Birth Canal (the Passage) cause Malpresentations & Malpositions

The bony pelvis may be the reason for the delay during labour. Abnormalities of uterus and cervix can also delay the progress of labour e.g., fibroid.

 Unsuspected fibroid in the lower uterine segment can impede descent of labour. The fetal head cervical dystocia can also cause delay in progress of labour.

 Cervical dystocia can also cause delay in progress of labour. Cervical dystocia means non-compliant cervix which effaces but fail to dilate.

Poor progress in the Second Stage of Labour

Delay in second stage of labour can occur during the latent or active phase of labour i.e., (pelvic or perineal phase). The causes are:

The midwife should not encourage the woman to bear down during the latent phase of 2^nd stage as this can lead to maternal exhaustion. The second stage may range from 30 minutes to 2 hours for multiparae and 1-3 hours in primiparae. This will not make the midwife to hurry the woman provided both the mother and fetus are in good condition.

During the active phase of labour intervention is not needed if the woman and baby are in good condition. If active phase becomes unduely prolonged, obstetrician should be invited to assess the woman instrumental delivery using forceps or vacuum extraction may be used to deliver the baby if risk of prolonging the labour further outweighs this intervention. Operative delivery may also be taken.

The Role of the Midwife in caring for a woman in poor progress of labour

1. Educator: Managing labour begins during antenatal; educate the woman on breathing techniques. Suitable food and drink to maintain energy level, positions during labour and delivery to enhance normal progress of labour.
2. Individualized care: Providing individualized care tailored to individual needs will help to reduce anxiety and stress that is often associate with prolonged labour. It help the woman and partner to build trust.
3. Accurate observations using partograph and partograph protocols will help to assess progress of care. This will help the midwife to prepare for and facilitate normal delivery and make provision for emergency.
4. Maintain adequate hydration of the woman and encourage her to always void urine at least every 2 hours.
5. Maintain the client’s autonomy by keeping the woman and her labour support partner about the progress, allow them to contribute to her care as thin will reduce anxiety.
6. Support: Additional support is given during progress of labour. Physiological and psychological supports are needed because some interventions like augmentation of labour are different from normal process.
7. Management of prolonged labour is a collaborate effort involving the woman, midwife, obstetric team and anaesthetist.
8. When labour is augmented the midwife titrates and manages the effects on the progress of labour, mother and the fetus.

Thanks for reading.  See you next time.