This document discusses various fetal malpresentations and malpositions that can occur during labor and delivery, including: - Occiput posterior position, which can cause a long and painful labor with increased risk of operative delivery. - Brow, face, and breech presentations, which are considered malpresentations. Face presentations have higher risks if chin is posterior. Breech presentations carry risks of natal and neonatal complications. - Diagnosis and management approaches are outlined for each condition, emphasizing the need for timely intervention and delivery to minimize risks to the mother and baby. Close monitoring and support for the mother are also important aspects of care.

1. UNIT 3 CONT’
FETAL DISTRESS
FETAL MONITORING
MATERNAL DISTRESS
UMBILICAL CORD ABNORMALITIES
MALPRESENTATION AND MALPOSITIONS
SHOULDER DYSTOCIA

2. 2

3. 3

4. 4

5. 5

6. 6

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

13. 13

14. 14

15. 15

16. 16

17. 17

18. 18

19. 19

20. 20

21. 21

22. 22

23. 23

24. 24

25. 25

26. 26

27. 27

28. 28

29. CORD PRESENTATION AND PROLAPSE OF THE
UMBILICAL CORD
LEARNING OBJECTIVES
At the end of this presentation the student midwife will be able to:
• Differentiate between presentation and prolapse of the umbilical cord
• Identify situations when this emengency might occur
• Discuss the midwife management of cord presentation and prolapse
• Discuss the possible consequences to the woman and the fetus

30. Definition
• Cord presentation: presentation of the cord occurs when a loop of cord lies
below the presenting part of the fetus and the membranes still intact
• Cord prolapse: when the membranes rupture it is referred to as cord
prolapse and loop may be visible in the vagina or hidden but in front of the
presenting part.
• Occult cord presentation: when a loop of cord lies beside rather than
before the presenting part, this will not be felt on vagina examination but
may be the cause of unexplained fetal distress in labor characterized by
early stages by deep early deceleration of the fetal heart.
• When confronted with a case of unexplained fetal distress the midwife
should consider the possibility of cord compression.

32. Causes
• Presentation and prolapse of the umbilical cord may occur in any
situation which results in a poorly fitting presenting part.some
conditions include:
• An unusually long umbilical cord
• Malpresentation such as shoulder and breech presentation especially
in a footling or flexed breech
• Preterm fetus more at risk because of higher incidence of
malpresentation especially before 34weeks of gestation
• Malposition such as occipitoposterior
• Multiple births

33. Causes cont’
• Multiparous women due lax abdominal musculature which favours
non-engagement of the fetal head until labor begins
• External cephalic version
• Polyhydramnios
• Low lying placenta previa
• High presenting part above the pelvic brim
• Artificial rupture of membranes (ARM)

34. Diagnosis
• May be diagnosed in pregnancy through ultrasound scanning
• Vaginal examination mat occasionally reveal a cord presentation with a soft
irregular rope like cord being palpated through the fetal membranes,
pulsation will be evident and will be synchronous with the fetal heart rate.
• If the presenting part is very high, the cord may float away from the
examining fingers
• Pulsation causes by the uterine arteries will be felt in the vaginal fornixes
and will be synchronous with maternal pulse
• Aucultation of fetal heart rate to differentiate from maternal pulsation

35. Management of cord prolapse
Key points in the management
• Call medical assistant urgently
• Relieve pressure on the cord
• Improve fetal oxygenation
• Expedite delivery
• Keep a clear, accurate and contemporaneous record

36. Management of prolapsed umbilical cord :
• Management: Temporizing measures to relieve cord pressure, Tocolysis with Terbutaline
0.25 mg SC
• Push cord back into vagina and maintain with gauze pack saturated with normal saline
• Vaginal retrograde pressure applied to presenting part
• Hand in vagina elevates presenting part
• Consider filling Bladder with 500-700 cc Saline
• Minimize handling of the cord
• Do not attempt to replace cord back into Uterus
• Adjust maternal position to reduce cord pressure
• Raise foot of the bed (Trendelenburg's Position)
• Sims' position
• Mother in left lateral decubitus position
• Genu-pectoral position
• Mother in knee-chest position
• Source: http://www.fpnotebook.com/ob/ld/UmblclCrdPrlps.htm with rationale for each
step added by Anne Grove CNM

37. Management cont’
• Adjust maternal position to reduce cord pressure
• Raise foot of the bed (Trendelenburg's Position)
• Sims' position
• Mother in left lateral decubitus position
• Genu-pectoral position
• Mother in knee-chest pos
• Source: http://www.fpnotebook.com/ob/ld/UmblclCrdPrlps.htm with rationale for each step added by Anne
Grove CNM

41. Management of umbilical cord prolapse cont’
PREPARE For CAESAREAN DELIVERY
 Educate the mother and family
 and reassurance and effective communication
 Call for helper more helpers

42. Management according to MOH PROTOCOL
Treat as an obstetric emergency and arrange for immediate medical
assistance (obstetrician, anaesthetist, neonatologist)
The mode of delivery will depend on whether a fetal heart is present
or absent and the stage of labour
Aim to maintain the fetal circulation by preventing / minimising cord
compression until birth occurs

43. Management of 1st stage of labor
If Cord pulsating
Determine stage of labor by vaginal examination
First stage of labor
• Arrange immediate delivery by caesarean section
• Administer Oxygen
• Ensure continuous fetal monitoring until in theatre and commencing
caesarean section or until after vaginal birth

44. Management of 1st stage of labor cont’
• The priority is to relieve pressure on the cord while
preparations are made for emergency caesarean
section.
• Where possible the bladder can be filled with normal
saline where there is delay to carry out the c/section
• Positioning the woman in the deep knee-chest
position (also known as Trendelenburg) so that the
pelvis and buttocks are elevated. Elevate the foot of
the bed where possible.
• Using sterile gloves, the midwife / medical officer
should insert their fingers into the vagina, identify
and carefully elevate the presenting part to reduce
the amount of cord compression and keep fingers
inside until delivery

45. Management of 1st stage of labor cont.’
• If the cord is protruding outside the vagina, the attending clinician
may attempt to push back the cord gently within the vagina
• Avoid excessive handling of the cord
• Acute intravenous tocolysis using β2 agonists (Salbutamol or
Terbutaline) to relieve pressure on the cord may be an effective
adjunct treatment

46. Management of 2nd stage of labor
If cord pulsating
• If the woman is in the second stage of labor and
vaginal birth is imminent and with the presenting part
engaged, prepare for vacuum extraction
• If vaginal delivery is not feasible, do immediately a
caesarean section
If Cord not pulsating
• Confirm fetal death with ultrasonography and/or CTG
• Allow labor to proceed as for vaginal birth of fresh
stillbirth

47. Prognosis/ OUTCOMES
• High perinatal mortality for delayed delivery >40
Prevention
•Do not perform artificial rupture of membranes if
fetal head high above the pelvic brim.

48. Summary
• The outcome is likely to be poor for the baby if action is not swift and
effective
• The midwife must recognize those who are at higher risk and know
what emergency action to take in the event of cord presentation and
prolapse
• Accurate record keeping is vital particularly in regards to times and
action taken
• Psychological care and debriefing after the event are essential for the
woman and her family.

49. MALPRESENTATIONS AND MALPOSITIONS
• LEARNING OBJECTIVES
• At the end of this session the student midwife will be able to:
• Have an understanding of the factors which predispose to
malposition's and malpresentations
• Recognize features of malpresentation and malposition and take the
appropriate action
• Consider the management and care that may facilitate normality and
ensure a safe and positive experience for the woman and baby

50. B. TYPES
Mal presentations:
1. Brow
2. Face
3. Breech
4. Transverse
5. Compound
Mal positions:
1. Occiput Posterior Position (OP): when the fetal occiput is directed towards the
mother’s spine or posteriorly
2. Intermediate positions (Bregma)

51. C. Causes
• Defects of the power: Laxity of the abdominal muscles, exaggerated
dextrorotation of the uterus
• Defects of passage: Contracted Pelvis, android pelvis, pelvic tumor,
uterine anomaly and placenta previa.
• Defect of passenger: Preterm fetus, macrosomia,
multiple pregnancy, poly hydramnios, anacephaly and
hydrocephaly, Intrauterine fetal death

52. A. MALPOSITION OF THE OCCIPUT
• Occipitoposterior position occurs in approximately 10% of all
labour,most of which end normally.
• Malposition may also be common with the use of epidural
anaesthesia
• Modern life style with less physical activity and poorer posture has
lead to an increase in the number

55. Causes
• Failure of internal rotation prior to delivery
• Direct cause is often unknown
• Associated with an android or anthropoid shaped pelvis

56. Antenatal Diagnosis
• Abdominal examination:
Inspection
There is a saucer shaped depression at or just below the umbilicus.
Palpation
The back is difficult to palpate; it is well out to the side
Limbs can be felt on both sides of the midline
The head is usually high
The occiput and sinciput are on the same level
Auscultation
The fetal heart can be heard in the midline or in the flank

57. Diagnosis during labor
• The woman may complain of continuous and severe backache
worsening with contractions
• Spontaneous rupture of membranes may occur at an early stage of
labor
• Contractions may be incoordinate
• There is slow decent of the head even with good contraction

58. Labor diagnosis cont’
• The woman may have a strong desire to push at the early stage of
labor
• Vaginal examination finding will depend upon the degree of decent of
the fetal head;
• locating the anterior fontanelle in the anterior part of the pelvis is
diagnostic
• The direction of the sagittal suture and location of the posterior
fontanelle will help to confirm the diagnosis

59. Management of labor
First stage:
• Labour with a fetus in occipitoposterior can be long and painful.
• Assist with pain management techniques such as massage,change of
position and posture,
• Give pharmacological pain relief
• Prevent dehydration and ketosis
• Correct any incoordinate uterine contractions with an oxytocin
• The urge to push before the cervix has become fully dilated may be
eased by a change in position and the use of breathing techniques

60. Management cont’
• Second stage:
• Full dilatation of cervix may be confirmed by a vaginal examination
• Encourage the woman to remain in upright position
• If contraction are weak and inefficient an oxytocin infusion may be
commenced
• The length of the second stage of labor is increased when the occiput
is posterior,with an increased risk of operative delivery.

61. COMPLICATIONS
• Early rupture of membranes
• Cord prolapse
• Prolonged labor
• Retention of urine
• Premature expulsive phase
• Infections
• Trauma to the mother’soft tissue
• Post traumatic stress disorders or postnatal depression
• Maternal exhaustion
• Fetal intracranial injury and hemorrhage
• Increased perinatal mortality and morbidity

62. Malpresentation
• Malpresentation refers to the orientation of the fetus and may be
diagnosed during pregnancy or labor.
• Any presentation other than vertex is termed a malpresentation and
therefore includes:
• Breech,face,shoulder, and brow
• As in malposition there is commonly an ill fitting presenting part
which is associated with early rupture of membranes.

63. BROW PRESENTATION
• The fetal head is partially extended with the frontal bones lying at the
pelvic brim.the presenting diameter is the mento-vertical (13.5cm)

64. B.BROW PRESENTATION

65. Causes and risk factors
• CPD
• Thyroid neoplasms
• Multiple loops of cord around fetal neck
• Fetal anomalies
• Polyhydramnios
• Prematurity
• PROM with unengaged head
• Uterine anomalies
• Placenta Previa
• External Cephalic Version
• Idiopathic
• More common in nulliparous women

66. Diagnosis
• Cephalic prominence and back are on same side
• FH heard in lower quadrants
• On vaginal exam:
• Anterior fontanel easily palpated
• Frontal suture easily felt, sagittal suture hard to reach
• Palpable supra orbital ridges, eyes, root of nose

67. Management and its complications
• Denominator is forehead
• Attitude of partial extension
• Mento vertical 13.5cm diameter presents
• Incidence 1 in 1000-3000
• Descent very slow, molding extreme
• Higher fetal mortality, traumatic brain injury r/t molding
Management: Cannot deliver vaginally unless converts to face (30%) or
vertex (20%). It is cesarean delivery

68. Management cont’
• On vaginal examination
• Presenting part is high
• The anterior fontanelle may be felt on one side of the pelvis and
orbital ridge,root of the nose at the other
• A large caput succedenum may mask these land marks if the woman
has been in labor for some time.

69. C.FACE PRESENTATION
Face presentation: Hyperextension of the fetal head

70. Types
Anterior (LMA, RMA)
• Longer labor
• 90% deliver vaginally
• More work for Mom
• NB: Facial and laryngeal edema –
watch for breathing difficulties for 24
hours, peds at delivery
Transverse (LMT, RMT)
• Majority rotate to LMA → MA
• Remainder either rotated with
forceps or delivered by c/s

71. Types cont..
Posterior (LMP, RMP)
• 30% of face presentations
• Most rotate anteriorly
• Persistent posterior cannot be
delivered vaginally

72. Diagnose
On vaginal examination:
• The face is palpable and the point of
reference is the chin. You should feel
the mouth and be careful not to
confuse it with breech presentation.
• It is necessary to distinguish the chin-
anterior position from chin- posterior
position

73. Management
If Chin-anterior position
• If the cervix is fully dilated: vaginal delivery
• If there is slow progress and no sign of
obstruction, augment labor
• If descent is unsatisfactory, perform a C/S
If Chin-posterior position
• Deliver by C/S

74. MIDWIFERY MANAGEMENT
• Call for help
• Reevaluate adequacy of pelvis
• Closely monitor mechanisms of labor
and identify if rotates to MP position
• Careful VEs so as not to damage eyes
• Gentle pressure on fetal brow to
maintain extension until chin is born
• Control head delivery, gradual flexion
and birth of remainder of head
• Neonatology inform incase of
resuscitation
• Reassurance to parents about extensive
edema
• Effective communication with
team,mother and partner.
• Give iv fluid

75. D.BREECH PRESENTATION
• A breech presentation occurs when the fetal buttocks lie lowermost
in the maternal uterus and the fetal head occupies the fundus
• The lie is longitudinal,the denominator is the sacrum,presenting
diameter is the bitrochanteric which measures 10cm.

76. t
TYPES OF BRRECH
• Complete – flexion at
thighs and knees (5-10%)
• Frank – flexion at thighs,
extension at knees (50-
70%)
• Footling – extension at
thighs and knees, single or
double (10-30%)
• Kneeling – extension at
thighs, flexion at knees,
single or double

77. Causes/ Risk factors
• Prematurity
• High parity
• Polyhydramnios
• Oligohydramnios
• Uterine anomalies, uterine neoplasms, contracted pelvis
• Placenta previa
• Multiple gestation
• Hydrocephaly, anencephaly, other fetal anomalies
• IUFD

78. Diagnosis
• Pt reports FM in lower abdomen/rectum
• Ballotable head felt in fundus
• Non-ballotable breech felt in lower abdomen
• FH heard at or above umbilicus
• On VE, high presenting part, negative findings
• Presenting part soft and irregular
• The buttocks and/or feet are felt, thick dark
meconium is normal

79. Criteria for vaginal breech delivery
• No Contraindications to vaginal birth
• No fetal anomaly that may interfere with vaginal birth
• EFW 2000-4000g
• GA 36+ weeks
• Flexed fetal head – NO hyperextension
• Frank breech
• Normal progress of labor
• Continuous EFM
• Skilled provider and c/s immediately available

80. Management cont
Varney’s 9 Steps/Criteria before Delivery of a Breech
1. Abdominal exam or sono/x-ray to r/o hyperextension of fetal head,
hydrocephalus, footling/kneeling breech
2. Complete cervical dilation
3. Completely assured of adequacy of pelvis
4. Empty bladder
5. Determine need for episiotomy and perform
6. Ensure effective maternal pushing
7. Prepare for full-scale NB resuscitation
8. Position woman in lithotomy, at edge of bed
9. Consulting physician at bedside or immediately available

81. Management cont..
Types of vaginal breech delivery
• Spontaneous – no traction, no manipulation
• Assisted – infant delivers spontaneously to umbilicus, maneuvers are used to
facilitate rest of delivery
• Total breech extraction – feet are grasped, entire fetus is extracted

82. Mechanism of labor
In breech presentations, three segments of the fetus go through the
mechanism of labor:
1. The buttocks and lower limbs
2. The shoulders and arms
3. The head
Mechanism of labor for Right Sacrum Anterior, R.S.A.:
• Descent occurs throughout for all three segments due to the force of
uterine contractions.
• I. The Buttocks:
• Engagement: has been achieved when the bitrochanteric
diameter has passed through the inlet of the pelvis with the
sacrum in the left anterior quadrant of the mother's pelvis and the
bitrochanteric diameter in the left oblique diameter of the
mother's pelvis. Lateral flexion occurs at the waist.

83. Mechanism cont’
• Internal Rotation: When the anterior hip meets
the resistance of the pelvic floor, it rotates
forward 45 degrees so that the bitrochanteric
diameter becomes anteroposterior. (RSA to RST)
• Birth of the Buttocks: by Lateral Flexion:
The anterior hip impinges under the pubic
symphysis; lateral flexion at the waist is increased;
the posterior hip is born over the perineum. Then
the anterior hip slips out from under the symphysis
and is born. The legs and feet usually follow
spontaneously

84. Mechanism cont’
• Restitution occurs as the buttocks
rotate 45 degrees (RST to RSA) in
response to internal rotation of
the shoulders.

85. • II. Shoulders and Arms:
• Engagement of the shoulders occurs with
the bisacromial diameter passing through
the pelvic inlet in the right oblique
diameter of the maternal pelvis.
• Internal Rotation occurs as the anterior
shoulder strikes one or both pelvic
sidewalls and rotates 45 degrees from the
right oblique diameter to the
anteroposterior diameter of the maternal
pelvis.
• Birth of the Shoulders by Lateral
Flexion:
• The anterior shoulder impinges
under the symphysis and the
posterior shoulder and arm are born
over the perineum as the baby's body
is lifted upward. Then the anterior
shoulder and arms pass out under the
symphysi

86. • III. The Head: When the shoulders are at the
outlet, the head is entering the pelvis.
• Engagement: occurs with the sagittal
suture in the left oblique diameter of the
pelvis. The occiput is in the right anterior
quadrant of the pelvis.
• Flexion: of the head will take place but
must be maintained.
• Internal Rotation: The occiput strikes the
pelvic sidewalls and rotates 45 degrees
anteriorly so that the sacrum becomes
position S.A. resulting in the sagittal suture
being in the anteroposterior diameter of
the pelvis.
• Birth of the Head: The nape of the neck
pivots under the symphysis and the chin,
mouth, nose, forehead, bregma and
occiput are born over the perineum by
flexion

87. A. GUIDELINES FOR SAFE DELIVERY OF A BREECH
1. Cervix fully dilated before pushing is allowed.
2. Bladder empty.
3. Episiotomy performed, unless perineum is very lax.
4. Delivery accomplished by maternal pushing —
rather than traction from below.
5. Intervention consists of aiding the steps of the
mechanism of labor to happen within safe time
limits.
6. Administration of iv fluid
7. Regular strong contractions

88. LOVESET MANOEVER(CLOCKWISE AND ANTI
CLOCWISE ROTATION)
6. Safe traction is made by
downward pull on the baby's
pelvis (by fingers on the iliac
crests and thumbs over the
sacro-iliac regions) or later after
the trunk has been delivered by a
finger hooked over each
shoulder.
7. Delivery of the shoulders
should be attempted only after
the scapulae can be seen.
From Williams 22nd Ed figure 24-8

89. LOVESET CONT’
8. Safe rotation of the trunk
is made by using the same
grasp on the baby's pelvis
and turning.
9. Delivery of the head
should be attempted only
after the hairline at the
sub-occipital region can
be seen.
From Williams 22nd Ed figure 24-9

90. PROCEDURE FOR DELIVERY OF A FLEXED BREECH
MAURICEAU-SMELLIE-VEIT MANOEUVRE
All steps as in procedure for normal delivery apply except where the following special
points replace them:
1. There should be no intervention ("hands off the breech") until the body is
born as far as the umbilicus.
2. When the umbilical cord can be seen, gently draw down a loop of cord,
placing this to the side or near the perineum, to avoid a pull on the cord or
unnecessary pressure. If the cord does not slip down with gentle traction,
omit this step.
3. With the next contraction, have the mother bear down strongly to deliver chest
and arms. Meanwhile, grasp the baby by its pelvis (see # 6 above), and when
the body is delivered as far as the axilla, guide it downward to release the
anterior shoulder and arm, then upward for the posterior shoulder and arm

91. MAURICEAU-SMELLIE VEIT CONT’
4. As soon as the body and shoulders are fully born,
rotate the back uppermost to ensure that the occiput
rotates anteriorly. Have an assistant apply suprapubic
pressure to maintain flexion of the infant's head until
the head is born. Rest the baby's body on your non-
dominant hand and forearm, hooking the index and
ring fingers of this hand on each malar eminences.
Place your other hand on the baby's upper back, with
the index finger hooked over one shoulder, and the
middle finger hooked over the other shoulder. Place
the hooking fingers as far away from the neck as
possible to avoid pressure on the cervical or brachial
nerve plexuses. As the mother bears down, make
downward and outward traction on the shoulders
until the hairline appears under the pubic arch.

92. Procedure for Delivery of a Flexed Breech
• Alternative: if no assistant is available to apply suprapublic pressure,
use the upper hand to apply suprapubic pressure to the head until the
hairline appears under the pubic arch

93. 5. Apply upward traction while elevating the infant's body, following the
curve of Carus. When the suboccipital region of the head pivots under
the symphysis pubis, lift the body 45°, until the infant's nose and
mouth are visible at the introitus. Complete delivery of the head by
gradually easing the vault out through continuing the upward lift of the
body.
Alternative: The upper hand grasps the baby by the ankles, maintaining
slight traction to ensure that the suboccipital region pivots under the
symphysis pubis. Lift the body about 45o until the nose and mouth are
visible at the introitus. With the lower hand , wipe off the nose and
mouth. Complete delivery of the head by gradually easing the vault out
through continuing the upward lift of the body.

94. COMPLICATIONS
• Extended arms
• Extended head
• Entrapment of the fetal head
• Damage to internal organs of the trunk.
• Fracture of bones of extremities.
• Injury to brachial plexus
• Entrapment of the after coming head
• Nuchal arm

95. Management of BREECH according to MOH guideline and protocol, 2012
• Consider external cephalic version at 37 weeks if all
requirements are met (Adequate amniotic fluid, placenta in fundal position, No
uterine anomalies, no previous uterine scar, availability of theatre)
• Ideally, every breech delivery should take place in a hospital with surgical
capability.
• Determine most favorable mode of delivery(WHO advises c/section,vaginal
delivery in emergency cases to minimize complications

96. Contra-indications
Unfavorable pelvis, primigravida, macrosomia,
severe prematurity, IUGR, placental insufficiency, footling breech,
hyperextension of fetal head, fetal anomalies, nuchal arm, PROM or non-
progressive labor
Note: Vaginal breech delivery is safe and feasible by a skilled health
provider

97. COMPOUND PRESENTATION
Definition:
Occurs when an arm prolapses
alongside with the presenting part

98. Diagnosis and management
On Vaginal Examination
Fingers/Arm is felt with the presenting part
Management
• Replace the arm and if successful continue with vaginal delivery
• If Contracted pelvis and/or cord prolapsed: Do a C – section

99. Oblique and transverse lie leading to shoulder
presentation
A shoulder presentation occurs as a result of a transverse or oblique lie.
Shoulder presentation is not uncommon and is only probmatic if the
fetus is not cephalic by 36 weeks of gestation
If uncorrected shoulder presentation will result in obstructed labor and
must be readily identified
The most commonest cause of an unstable lie and shoulder presentation
is laxity of the uterine and abdominal muscles
Seen most frequently on women of high parity

100. Causes
• Placenta previa is the most commonest cause
• Persistent oblique lie
• Multiple pregnancy
• Polyhydramnios
• Uterine abnormality
• Contracted pelvis
• Large uterine fibroid
• Over distended bladder

101. Diagnosis
• Abdominal examination: the shape of the uterus appears too broad
with fetal pools felt on either side of the abdomen while the fundus is
usually low
• Palpation will reveal the fetal head on one side and the breech on the
other and no presenting part within the pelvis
• In obliques lie the fetal head or breech is found in one or other iliac
fossa
• Ultrasound may be used to confirm the diagnosis

102. Management
• After 36 weeks the doctor may attempt to correct the lie by external
cephalic version to a longitudinal lie and cephalic presentation
• Ultrasound examination to exclude placenta previa,fetal and uterine
abnormalities
• Vaginal examination to detect any abnormalitiessuch as contracted pelvis
• If the lie continues to be tranverse or obliques then c/section should be
performed
• Effective communication
• Psychological support
• Adequate fluid intake
• Monitor contraction,fetal heart rate and act accordingly.

103. Complications
• Arm prolapse
• Infection
• Umbilical cord prolapse
• Uterine rupture
• Fetal and maternal death

104. Summary
• Malpresentation and malposition of the fetus may increase the risk of
fetal and neonatal morbidity and mortality
• The midwife should ensure that the woman and her partner feel
prepared and supported for birth
• Effective communication and team work are crucial in the provision of
safe and appropriate care to women and their babies
• Manoeuvres and other skills based on physiological and evidence –
based principles should be practiced by those providing care to
women and their babies on a regular bases.

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