Fetal malpresentation

Breech presentation is the most commonly encountered malpresentation. Since publication of the Term Breech Trial that showed benefits for the fetus in undertaking caesarean section, there has been a large shift in practice. Nonetheless the fact remains that most babies will not be compromised by planning a vaginal birth, and maternal requests for vaginal delivery are not unreasonable. Many preterm fetuses and second twins presenting breech are still delivered vaginally, and the art of vaginal breech delivery must not be lost. Skills can be taught with the use of mannequins. Fetal malpresentations other than breech are infrequently encountered, and there is little evidence to guide practice. Face presentations pose few problems in labour except where the mentum remains posterior. Brow presentation does not automatically equate to the need for caesarean section, as some will correct as labour progresses. Shoulder presentation is encountered with transverse lie, with the attendant risk of cord prolapse and fetal compromise should labour ensue. There is a place for attempting external version if the membranes are intact, with immediate facilities for caesarean section if unsuccessful. If caesarean section is undertaken it is important to keep the membranes intact when opening the uterus to allow easier manipulation and delivery.