From the Guidelines
Abnormal fetal posture, also known as intrauterine fetal position, should be managed with careful assessment and appropriate interventions, prioritizing cesarean delivery as the safest approach for persistent abnormal presentations. When encountering an impacted fetal head during cesarean delivery, techniques such as uterine relaxation, abdominal cephalic disimpaction, manual vaginal disimpaction, reverse breech extraction, and the Patwardhan method can be employed to facilitate delivery 1.
Key Considerations
- Continuous fetal monitoring is essential to detect any signs of distress during labor
- Maternal position changes, such as hands and knees or side-lying, may encourage spontaneous conversion to a more favorable position for mild deflexed attitudes detected early
- External cephalic version is not typically effective for attitude abnormalities
- Adequate pain management should be provided, as abnormal presentations often cause more discomfort during labor
- Ultrasound guidance during labor can help confirm the presentation and track any changes
Specific Presentation Considerations
- For face presentations, mentum anterior position offers the best chance of success for vaginal delivery, while mentum posterior generally requires cesarean delivery
- The underlying cause of the abnormal attitude should be investigated, as it may be related to fetal anomalies, uterine abnormalities, or placental location issues
- Neonatal teams should be alerted when delivering infants with abnormal attitudes, as these babies may have increased risk of birth trauma, including facial edema, bruising, or nerve injuries that require immediate attention after birth. In the context of real-life clinical medicine, it is crucial to prioritize the safety of both the mother and the fetus, and cesarean delivery is often the most prudent approach for abnormal fetal posture, as supported by the most recent and highest quality study available 1.
From the Research
Management of Abnormal Fetal Posture
The management of abnormal fetal posture, also known as intrauterine fetal position, is crucial to prevent complications during labor and delivery.
- Fetal malpresentation, malposition, and asynclitism are common determinants of a protracted active phase of labor, arrest of dilatation during the first stage, and arrest of descent in the second stage 2.
- Intrapartum sonography can be used to diagnose fetal malposition, malpresentation, and asynclitism, and is more accurate than vaginal examination 2.
- Transabdominal sonography can be used to assess the fetal head position and attitude, and can be performed by clinicians with basic ultrasound skills 2.
- Fetal attitude can be evaluated using sonographic parameters such as the occiput-spine angle and the chin-chest angle 2.
- Maternal postures can be used to correct fetal malposition in late pregnancy, but more research is needed to understand the effect of positional interventions on pregnancy outcomes 3.
Diagnosis and Assessment
- Fetal malposition is associated with maternal and fetal complications, including prolonged labor, fetal distress, and increased risk of perineal trauma and anal sphincter injuries 3.
- Continuous fetal heart rate monitoring is the most common form of surveillance in the intrapartum period, while nonstress test, biophysical profile, and contraction stress test are used in the antepartum period 4.
- Fetal monitoring during pregnancy is used to prevent fetal death, and pediatricians who understand the goals, methods, and interpretation of fetal testing can communicate more effectively with the delivering obstetric team 5.
Interventions
- Positional interventions in late pregnancy may be used to correct fetal malposition, but more research is needed to determine the effectiveness of these interventions 3.
- Intrapartum sonography can be used to guide instrumental delivery and verify the occiput position before performing an instrumental delivery 2.