MALPRESENTATION--INCIDENCE AND CAUSES.
Malpresentation is defined as when the presenting part of foetus is other than normal vertex of foetal head. It includes breech, face, brow, shoulder, compound and cord presentations. In vast majority of deliveries near term, the foetus presents by the head with the best fit into the lower pelvis. More than 95% of foetuses at term present in labour by the vertex. In modern obstetrics, the incidence of malpresentations has fallen due to reducing parity. Among malpresentations, breech presentation is the most common followed by transverse lie with shoulder presentation and face presentation, others like brow, compound and cord presentations are less common. Congenital anomalies and perinatal mortality are increased with malpresentations.
MATERIALS AND METHODS
A retrospective study of malpresentation was conducted in Obstetrics and Gynaecology Department for a period of 5 years from 1st January 2012 to 31st December 2016 at MGMMCH, Jamshedpur, Jharkhand. There were 28,431 deliveries conducted with 1099 malpresentations with an incidence of 3.87%. Different variables such as parity, booked-unbooked case, maternal risk factors, type of malpresentation, mode of delivery, foetal anomalies associated with malpresentation were analysed and reviewed to see its association with maternal and perinatal outcome. All history sheets, labour room records and operative record were scrutinised and relevant information was extracted.
Total numbers of deliveries conducted in Obstetrics and Gynaecology Department for a period of 5 years from 1st January 2012 to 31st December 2016 at MGMMCH, Jamshedpur, Jharkhand were 28,431. Out of these 1099 (3.87%) patients presented with malpresentation. Breech presentation is the commonest 811 (73.79%), transverse lie with shoulder presentation are 170 (15.47%), face presentation are 64 (5.82%), compound presentations are 23 (2.09%), cord presentations are 20 (1.82%) and brow presentation are 11 (1.00%).
The incidence of total malpresentations is 3.87% among 28,431 deliveries conducted.
Commonest malpresentation was breech (2.85%) followed by transverse lie (0.60%), face presentation (0.23%), compound presentation (0.08%), cord presentation (0.07%) and brow presentation (0.04%).
Majority of the cases (62.97%) in our study were not booked in the hospital for antenatal care.
Most of the foetal malpresentations (45.38%) occurred in primi para followed by 26.92% in para 2.
In the present study breech was the most common malpresentation, 334 (41.18%) cases were delivered by vaginal route. Among them 29.22% had assisted breech delivery, 11.96% had spontaneous breech delivery. Majority of breech presentations (58.82%) were delivered by caesarean section.
In the present study prematurity was the aetiological factor, accounting to 7.92% of the cases, 25.93% accounted to multiparity, 2.47% presented with uterine anomalies and 4.64% contracted pelvis, 3.10% presented with disorders of amniotic fluid volume and 1.09% cases had placenta previa and 6.39% accounting to twins.
Majority of about 1065 cases had no anomalies associated with malpresentation. In the present study, 34 cases with malpresentations delivered anomalous babies. Among them 10 babies had hydrocephalus, 7 were born with congenital talipes equino varus, 11 were anencephaly babies and 6 were gastroschisis.
In the present study, 15.37% babies were still birth associated with malpresentation, neonatal death was seen in 7.10%.
Identification of malpresentations and their aetiological factors is of vital importance to reduce perinatal morbidity and mortality. In the present study, 1099 cases of malpresentations were identified among 28,431 deliveries in MGMMCH Jamshedpur, Jharkhand. According to 11th edition of Munro Kerr's operative obstetrics, incidence of breech at term is 3%-4%, face presentation is 1 in 500 i.e. 0.2%, brow is 1 in 1000 i.e. 0.1%, transverse lie is 1 in 500 births i.e. 0.2%.  In the present study 2.85% accounted to breech presentation, 0.60% of cases were transverse lie, 0.23% were face presentation, brow accounted to 0.04% of the cases, 0.08% were compound presentation and 0.07% were cord presentation. This was similar to study conducted by Noor et al. 
In this study, 62.97% were unbooked cases, which was similar to other studies. Vijayalakshmi et al reported 65 were unbooked cases  and Noor et al reported 276 unbooked cases.  In the present study, 45.38% occurred in primigravidae. Noor et al showed 25.17% of the cases were in primigravidae and Vijayalakshmi et al reported 75% of the cases were in multipara.
In the present study breech was the most common malpresentation, 334 (41.18%) cases were delivered by vaginal route. Among them 29.22% had assisted breech delivery and 11.96% had spontaneous breech delivery. This report was similar to Noor et al who reported assisted breech delivery in 65.4%, spontaneous breech delivery in 20.9% and breech extraction in 5.9%. 
In the present study face presentation accounted to 5.82% cases of malpresentation, of which 74.7% were delivered by caesarean section. Benedetti TJ et al reported caesarean section in 50% of the cases. Noor et al reported 33.3% underwent caesarean section. 
In the present study, 34 cases with malpresentations delivered anomalous babies. Among them 10 babies had hydrocephalus, 7 were born with congenital talipes equino varus, 11 were anencephaly babies and 6 were gastroschisis. Similar observations were made in other studies. Noor et al reported 8 cases with malpresentations, among them 5 had hydrocephalus, 3 presented with clubfoot, anencephaly and sacrococcygeal teratoma. 
In the present study, prematurity was the aetiological factor accounting to 7.92% of the cases, 25.93% accounted to multiparity, 2.47% presented with uterine anomalies and 4.64% contracted pelvis, 3.10% presented with disorders of amniotic fluid volume and 1.09% cases had placenta previa, 6.39% accounting to twins. Similar observations were made in other studies; Vijayalakshmi et al reported multiparity as the most common aetiological factor (75 cases), 10 cases had uterine anomalies, 7 presented with placenta previa, 3 cases had contracted pelvis and 3 had twin gestation and in 2 cases was not known. 
In the present study, 15.37% babies were still birth associated with malpresentation and neonatal death was seen in 7.10%.
Management of abnormal presentation is a continuing challenge to the obstetrician. Education about diagnosis of malpresentation and identification of aetiological factors should be imparted to health care personnel to enable early referral to higher centres for specialist services. Delivery in malpresentations should be planned at centres which have expertise in conducting vaginal delivery in malpresentations with good intrapartum monitoring and with facilities for caesarean section for better foetomaternal outcome.
 Munro Kerr's operative obstetrics. 11th edn. Elsevier Chapter 9, 14.
 Noor S, Faiz NR, Murad S. Malprentation incidence and causes. JPMI 2011;15(1):33-8.
 Vijayalakshmi B, Purra P. A clinical stdy of outcome of labour in transverse lie. JEBMH 2015;2(34):5232-9.
 Benedetti TJ, Lowensohn RI, Truscott AM. Face presentation at term. Obstet Gynecol 1980;55(2):199-202.
Anjali Srivastava (1), Manjula Srivastava (2), K. M. Preeti (3)
(1) Associate Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.
(2) Assistant Professor, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.
(3) Junior Resident, Department of Obstetrics and Gynaecology, Mahatma Gandhi Memorial Medical College and Hospital.
'Financial or Other Competing Interest': None.
Submission 27-10-2017, Peer Review 20-12-2017, Acceptance 26-12-2017, Published 08-01-2018.
Dr. Manjula Srivastava, Duplex-12, Vasundhara Estate, NH-33, Near Irrigation Colony, Dimna-831018,1SR.
Table 1. Incidence of Malpresentation Presentation No. of Cases Prevalence (n=28431) (100%) Vertex 27332 96.13% Non-Vertex 1099 3.87% Table 2. Distribution of Malpresentation Type No. of Cases Prevalence (n=28431) (3.87%) Breech 811 2.85% Transverse 170 0.60% Face 64 0.23% Compound 23 0.08% Cord 20 0.07% Brow 11 0.04% Table 3. Booked-Unbooked Cases Cases No. of Cases Prevalence (n=1099) (100%) Booked 407 37.03% Unbooked 692 62.97% Table 4. Distribution of Cases in Relation to Parity Parity No. of Cases Prevalence (n=1029) (100%) 1 467 45.38% 2 277 26.92% 3 173 16.81% 4 85 08.26% 5 or More 27 02.62% Table 5. Mode of Delivery in Breech Presentation Mode of Delivery No. of Cases Prevalence (n=811) (100%) Spontaneous breech delivery 97 11.96% Assisted breech delivery 237 29.22% Caesarean section 477 58.82% Table 6. Maternal Risk Factors Risk Factors No. of Cases Prevalence (n=1099) (100%) Prematurity 87 07.92% Twins 70 06.39% Polyhydramnios 06 00.55% Oligohydramnios 28 02.55% Placenta previa 12 01.09% Uterine malformations 27 02.47% Foetal anomalies 34 03.09% Multiparity 285 25.93% Contracted pelvis 51 04.64% Unknown causes 499 45.40% Table 7. Foetal Anomalies associated with Malpresentation Foetal Anomaly No. of Cases (n=1099) Hydrocephalus 10 Anencephaly 11 Gastroschisis 06 CTEV 07 No Anomaly 1065 Table 8. Status of Babies associated with Malpresentation Babies Status No. (n=1099) Prevalence (100%) Alive 852 77.53% N.N.D. 78 07.10% Still Birth 169 15.37%
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|Title Annotation:||Original Research Article|
|Author:||Srivastava, Anjali; Srivastava, Manjula; Preeti, K.M.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jan 8, 2018|
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