malpresentation

Malpresentation is a term used in obstetrics to describe a fetus that is not presenting in the normal cephalic, occiput-first position at the time of delivery. It encompasses nonvertex presentations such as breech (buttocks or feet first), transverse or oblique lie, and nonvertex presentations like face or brow presentations, as well as malposition such as occiput posterior.

Many malpresentations occur earlier in pregnancy or during labor but may resolve before delivery. Persistent malpresentation becomes clinically significant when labor begins or delivery is imminent, as it can affect the mode and safety of birth. Risk factors include placenta previa, uterine anomalies, multiple pregnancy, fetal anomalies, polyhydramnios, preterm birth, and uterine fibroids, as well as abnormal fetal size or pelvic anatomy.

Diagnosis is usually made by physical examination with Braxton Hicks and Leopold maneuvers, followed by ultrasound to confirm presenting part, fetal lie, and position and to assess placental location and amniotic fluid. Malpresentation raises concerns for cord prolapse in nonvertex presentations and may influence the plan for delivery.

Management depends on the type of malpresentation and gestational age. External cephalic version (ECV) may be attempted for eligible breech pregnancies near term. If ECV fails or is contraindicated, planned cesarean delivery is commonly recommended for breech or transverse lies, while some face or brow presentations may require cesarean or, in very selected cases with skilled teams, vaginal delivery. In labor, ongoing assessment is essential to ensure fetal well-being and maternal safety.