fetus in vertex presentation icd 10

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ICD-10-CM Coding for Malposition/Malpresentation of Fetus

Mar 27, 2024

Fetal positioning within the uterus is not of much concern until the third trimester which is when most fetuses assume a head down position in preparation for descent into the birth canal. Optimal fetal positioning makes labor and delivery faster, easier and safer for both the fetus and the mother. Fetal malposition or malpresentation may lead to difficulties with labor and delivery and can be an indication for as assisted vaginal birth or delivery by cesarean section. Proper code assignment for malposition and malpresentation is necessary to support performance of these procedures for these conditions.

What is Fetal Presentation, Position and Lie?

Fetal presentation, position and lie describe the fetus in relation to the uterus, cervix and maternal pelvis.

• Fetal presentation refers to the part of the fetus that is lined up to enter the maternal pelvis first/lead the fetus through the cervix (e.g., occiput, chin, shoulder, foot).
• Fetal position refers to the position of the fetal head as it exits the birth canal. This indicates the direction the fetus is facing (anterior, posterior, transverse).
• Fetal lie refers to how the long axis of the fetus (think spinal column) lines up in relation to the uterus. The lie can be longitudinal (straight up and down), oblique (diagonal) or transverse (sideways). 

Normal or optimal presentation, position and lie for vaginal obstetric delivery is:

• Presentation: Vertex/cephalic (the crown of the head) with chin tucked to chest and arms crossed over the chest
• Position: Occiput anterior (the baby is facing toward the mother’s spine)
• Lie: Longitudinal (straight up and down).

What is Malpresentation/Malposition?

Malpresentations and malpositions result when one or a combination of the fetal presentation, position or lie deviates from the normal/optimal status. Below are examples of malpresentations, malpositions, and abnormal lie.

Malpresentation

• Frank breech: Buttocks down with feet near the head
• Complete breech: Knees bent with feet near the buttocks
• Incomplete breech: One knee bent with one foot near the buttocks
• Footling breech: One or both feet are the presenting part
• Face/Brow/Chin (mentum): The fetus’ neck is hyperextended (arched) making the face, brow or chin the presenting fetal part. The degree of hyperextension determines which part is presenting. Greater extension presents the face/chin, less extension presents the brow.
• Shoulder/arm: The shoulder or arm is the presenting part of the fetus
• High head at term: The fetal head does not engage in the pelvis
• Compound: A fetal extremity presents alongside the part of the fetus closest to the birth canal (e.g., hand/arm presents alongside the head)

Malposition

• Occipitoposterior: The fetus’ occiput (back of the head) is against the posterior (spinal) side of the mother and the fetus is facing toward the mother’s abdomen. This is sometimes referred to as “sunny side up”.
• Occipitotransverse: This position is halfway between an anterior and a posterior position. The side of the fetus is perpendicular to the mother’s spine and the fetus is facing outward toward the mother’s right or left thigh. 

Abnormal Lie

• Oblique: The fetus is lying diagonally.
• Transverse: The fetus is lying sideways.
• Unstable: The fetus does not maintain a fixed longitudinal lie after 36 weeks gestation.

How is Malpresentation/Malposition Coded in ICD-10-CM?

Codes for malpresentation and/or malposition of fetus are found in category O32 Maternal care for malpresentation of fetus. Notice that the description of each code specifies that the code is used to report maternal care for a specific type of malpresentation/malposition.

032.0 Maternal care for unstable lie

032.1 Maternal care for breech presentation

• Maternal care for buttocks presentation
• Maternal care for complete breech
• Maternal care for frank breech
• Excludes 1: footling presentation (032.8); incomplete breech (032.8)

032.2 Maternal care for transverse and oblique lie

• Maternal care for oblique presentation
• Maternal care for transverse presentation

032.3 Maternal care for face, brow and chin presentation

032.4 Maternal care for high head at term

• Maternal care for failure of head to enter pelvic brim

032.6 Maternal care for compound presentation

032.8 Maternal care for other malpresentation of fetus

• Maternal care for footling presentation
• Maternal care for incomplete breech

032.9 Maternal care for malpresentation of fetus, unspecified

Assignment of codes is determined by a applying a combination of direction found in the Alphabetic Index, the Tabular List and the ICD-10-CM official guidelines to the documentation in the medical record.

The Alphabetic Index

Selection of the correct code to report malpresentation/malposition is directed by a valid search of the Index to Diseases and Injuries. There are several ways the index can be searched to arrive at codes for malpresentation/malposition depending on the terminology used in the documentation.

Successful searches include:

Delivery  cesarean (for)     breech presentation O32.1    chin presentation O32.3    high head at term O32.4     Etc.

Delivery    complicated       by          malposition, malpresentation             without obstruction                 breech O32.1                 compound O32.6                 face (brow) (chin) O32.3                 footling O32.8       high head O32.4      oblique O32.2      specified NEC O32.8      transverse O32.2      unstable lie O32.0

Delivery    complicated       by          prolapse              arm or hand O32.2              foot or leg O32.8

Failure   descent of head (at term) of pregnancy (mother) O32.4   engagement of head (term of pregnancy) (mother) O32.4

Pregnancy    Complicated by       mentum presentation O32.3        oblique lie or presentation O32.2        transverse lie or presentation O32.2        unstable lie O32.0        Etc.

Pregnancy    Complicated by       presentation, fetal -see Delivery, complicated by, malposition

Breech presentation (mother) O32.1

Transverse     lie (mother) O32.2  

Unstable     lie (mother) O32.0

Presentation, fetal -see Delivery , complicated by, malposition

The Tabular List

There are notes at the beginning of category O32 that provide important direction that must be followed when assigning codes from this category. For example:

• Codes from this category are assigned when malpresentation/malposition is the reason for maternal care
• When malpresentation causes obstructed labor, a code from category O64 is assigned rather than from category O32
• A 7 th character that reports the affected fetus is assigned to codes for malpresentation/malposition

O32 Maternal care for malpresentation of fetus

• Includes: the listed conditions as a reason for observation, hospitalization or other obstetric care of the mother, or for cesarean delivery before onset of labor

Excludes1: malpresentation of fetus with obstructed labor (064.-)

One of the following 7th characters is to be assigned to each code under category 032. 7th character 0 is for single gestations and multiple gestations where the fetus is unspecified. 7th characters 1 through 9 are for cases of multiple gestations to identify the fetus for which the code applies. The appropriate code from category 030, Multiple gestation, must also be assigned when assigning a code from category O32 that has a 7th character of 1 through 9.

• 0 - not applicable or unspecified
• 1 - fetus 1
• 2 - fetus 2
• 3 - fetus 3
• 4 - fetus 4
• 5 - fetus 5
• 9 - other fetus

Note: Codes from category O32 only have 4 characters, so a placeholder character of “X” is needed in the 5 th and 6 th character places to ensure the character value assigned to indicate the affected fetus is in the 7 th character place.

The ICD-10-CM Coding Guidelines

According to ICD-10-CM Official Guideline I.C.15.b.4 Selection of OB Principal or First-listed Diagnosis When a Delivery Occurs , malpresentation/malposition is sequenced as the principal diagnosis when:

• Malpresentation/malposition is the reason for admission.
• Malpresentation/malposition and another condition prompt the admission but malpresentation/malposition is most related to the delivery (e.g., it leads to instrumental vaginal delivery or is the reason for admission for cesarean section)
• The patient is admitted with no other complications of pregnancy and develops malpresentation/malposition post admission and malpresentation/malposition necessitates maternal care including, but not limited to: repositioning of the patient, rotation of fetal head, internal/external version, instrumental vaginal delivery (forceps/vacuum extraction).

In a small number of cases, how the fetus is situated may be a malpresentation/malposition but the malpresentation/malposition does not require maternal care. If this is the case, a code from category O32 is not assigned.

Example: A patient is admitted in advanced premature labor. The fetus is in vertex presentation, but in occiput posterior position (sunny side up). Due to the small size of the fetus, it is delivered via a normal, spontaneous vaginal delivery in the occiput posterior position.

Since the malposition of the fetus did not necessitate maternal care a code from category O32 is not assigned. This is consistent with the coding guidelines for selection of additional or other diagnoses.

Section III. Reporting Additional Diagnoses

GENERAL RULES FOR OTHER (ADDITIONAL) DIAGNOSES

For reporting purposes, the definition for “other diagnoses ” is interpreted as additional clinically significant conditions that affect patient care in terms of requiring:

clinical evaluation; or

therapeutic treatment; or

diagnostic procedures; or

extended length of hospital stay; or

increased nursing care and/or monitoring

Malpresentation/Malposition as an Indication for Cesarean Section

In cases where vaginal delivery is contraindicated because of malpresentation, malposition or abnormal lie, a cesarean section may need to be performed to deliver the fetus safely.

The Includes note under category O32 in the Tabular List indicates codes from this category are intended to be reported when the decision to deliver a patient via cesarean section, secondary to malpresentation or malposition of the fetus, is made before the onset of labor .

This distinction is important because when a patient presents in labor with the intent to delivery vaginally and malpresentation/malposition results in the decision to deliver the patient via cesarean this is typically because the malpresentation/malposition of the fetus has resulted in obstructed labor that precludes vaginal delivery. These circumstances are reported with a code from category O64 Obstructed labor due to malposition and malpresentation of fetus rather than with a code from category O32 .

Malpresentations and malpositions result when one or a combination of the fetal presentation, position or lie deviates from the normal/optimal status. ICD-10-CM codes to report malpresentation/malposition are assigned from category O32 Maternal care for malpresentation of fetus when the malpresentation/malposition is the reason for maternal care. Code selection is guided by documentation in the medical record and a valid search of the Index to Diseases and Injuries. The ICD-10-CM Tabular List and coding guidelines provide significant direction regarding the requirements and structure for assigning a valid code and sequencing of codes from category O32 as the principal diagnosis.

References ICD-10-CM Index to Diseases and Injuries ICD-10-CM Official Guidelines for Coding and Reporting ICD-10-CM Tabular List

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus.

b. Presentation/Presenting Part.

Presentation refers to that part of the fetus that is coming through (or attempting to come through) the pelvis first.

(1) Types of presentations (see figure 10-1). The vertex or cephalic (head), breech, and shoulder are the three types of presentations. In vertex or cephalic, the head comes down first. In breech, the feet or buttocks comes down first, and last–in shoulder, the arm or shoulder comes down first. This is usually referred to as a transverse lie.

(2) Percentages of presentations.

(a) Head first is the most common-96 percent.

(b) Breech is the next most common-3.5 percent.

(c) Shoulder or arm is the least common-5 percent.

(3) Specific presentation may be evaluated by several ways.

(a) Abdominal palpation-this is not always accurate.

(b) Vaginal exam–this may give a good indication but not infallible.

(c) Ultrasound–this confirms assumptions made by previous methods.

(d) X-ray–this confirms the presentation, but is used only as a last resort due to possible harm to the fetus as a result of exposure to radiation.

c. Attitude.

This is the degree of flexion of the fetus body parts (body, head, and extremities) to each other. Flexion is resistance to the descent of the fetus down the birth canal, which causes the head to flex or bend so that the chin approaches the chest.

(1) Types of attitude (see figure 10-2).

(a) Complete flexion. This is normal attitude in cephalic presentation. With cephalic, there is complete flexion at the head when the fetus “chin is on his chest.” This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.

(b) Moderate flexion or military attitude. In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.

(c) Poor flexion or marked extension. In reference to the fetus head, it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.

(d) Hyperextended. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.

(2) Areas to look at for flexion.

(a) Head-discussed in previous paragraph, 10-2c(1).

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

(d) Arches of the feet-rested on the anterior surface of the legs.

(e) Arms-crossed over the thorax.

(3) Attitude of general flexion. This is when all of the above areas are flexed appropriately as described.

d. Station.

This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother’s pelvis. Measurement of the station is as follows:

(1) The degree of advancement of the presenting part through the pelvis is measured in centimeters.

(2) The ischial spines is the dividing line between plus and minus stations.

(3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3).

(4) The ischial spines is zero (0) station.

(5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.

e. Engagement.

This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged, it (fetus) does not go back up. Prior to engagement occurring, the fetus is said to be “floating” or ballottable.

f. Position.

This is the relationship between a predetermined point of reference or direction on the presenting part of the fetus to the pelvis of the mother.

(1) The maternal pelvis is divided into quadrants.

(a) Right and left side, viewed as the mother would.

(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top half is anterior and the bottom half is posterior.

(c) The quadrants never change, but sometimes it is confusing because the student or physician’s viewpoint changes.

NOTE: Remember that when you are describing the quadrants, view them as the mother would.

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

1 Occiput (O). This refers to the Y sutures on the top of the head.

2 Brow or fronto (F). This refers to the diamond sutures or anterior fontanel on the head.

3 Face or chin presentation (M). This refers to the mentum or chin.

(b) Breech or butt presentation.

1 Sacrum or coccyx (S). This is the point of reference.

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

2. Scapula (Sc) or its upper tip, the acromion (A) would be used for the point of reference.

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

1 The first letter of the code tells which side of the pelvis the fetus reference point is on (R for right, L for left).

2 The second letter tells what reference point on the fetus is being used (Occiput-O, Fronto-F, Mentum-M, Breech-S, Shoulder-Sc or A).

3 The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior-P, transverse or in the middle-T).

(b) Each presenting part has the possibility of six positions. They are normally recognized for each position–using “occiput” as the reference point.

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

(c) A transverse position does not use a first letter and is not the same as a transverse lie or presentation.

1 Occiput at sacrum (O.S.) or occiput at posterior (O.P.).

2 Occiput at pubis (O.P.) or occiput at anterior (O.A.).

(4) Types of breech presentations (see figure10-4).

(a) Complete or full breech. This involves flexion of the fetus legs. It looks like the fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously.

A–Complete. B–Frank. C–Incomplete.

(b) Frank and single breech. The fetus thighs are flexed on his abdomen. His legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver.

(c) Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first.

(5) Observations about positions (see figure 10-5).

(a) LOA and ROA positions are the most common and permit relatively easy delivery.

(b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache.

(c) Knowing positions will help you to identify where to look for FHT’s.

1 Breech. This will be upper R or L quad, above the umbilicus.

2 Vertex. This will be lower R or L quad, below the umbilicus.

(d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts, arms and legs (see figure 10-5 A). If delivered in that position, the infant will come out looking up.

(e) An occiput in the anterior quadrant means that you will feel a more smooth back (see figure 10-5 B). If delivered in that position, the infant will come out looking down at the floor.

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Compound Presentations- Causes, Effects on Labor, Complications, and Management

Compound presentation occurs when one extremity emerges concurrently with the part of the fetus closest to the birth canal.

Dr. Ankita Balar

Medically reviewed by

Dr. Richa Agarwal

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What Are Compound Presentations?

Compound presentations are rare obstetric occurrences that frequently cause the care team to become quite anxious. A prenatal presentation known as a compound presentation occurs when one extremity develops concurrently with the part of the fetus closest to the birth canal. A fetal hand or arm typically presents with the head during compound fetal presentations.

A fetal presentation is considered compound when one or more limbs prolapse together with the head or breech, both of which enter the pelvis simultaneously. This group excludes footling breech or shoulder presentations. In 15 to 20 percent of instances, the umbilical cord prolapses along with the condition.

Compound Presentations Are Classified As,

• Cephalic presentation is also called fetal presentation of the baby. Cephalic presentation is classified into vertex, face, and bow presentation. Vertex baby presentation is the common form of cephalic presentation in which the baby is in a down position toward the spine, and the baby's chin is tucked into the chest. Vertex baby presentation is when the head comes first in the birth canal. Face presentation baby is the presentation in which the fetus's head is extended, and it goes first into the face of the pelvis. A baby with a face presentation can be delivered through the vagina. However, in some cases, C-section is indicated. Cephalic presentation is with prolapse of,

One or both upper limbs (arm and hand).

One or both lower limbs (leg and foot).

Arms together with legs.

2. Breech presentation is when the fetus's buttocks and feet pass through the cervix first. It is accompanied by an arm or hand prolapse.

The combination of the head with the hand or arm is by far the most common. On the other hand, the head-foot and breech-arm groups are relatively infrequent. It is unusual for a hand or foot to prolapse alongside the head. The prolapse of the umbilical cord might complicate any combination, which makes it the main issue.

What Causes Compound Presentations?

Different mechanisms can result in compound fetal presentation from several clinical contexts. The causes of compound presentations include any circumstances that prevent the presenting component from filling and occluding the pelvic entrance.

Instances of compound presentation include,

Due to early gestational age, multiple gestations , polyhydramnios (excessive amniotic fluid accumulation), or a large maternal pelvis in comparison to fetal size, the fetus does not fully occupy the pelvis, which leaves an opportunity for a fetal extremity to prolapse.

When the presenting part is still high, the membranes rupture, allowing the amniotic fluid to flow and carry a fetal extremity, the umbilical cord, or both to the birth canal.

Preterm labor (when the baby is born too early or before six weeks of the due date).

External Cephalic Version (ECV) - A fetal limb (often the hand or arm, but occasionally the foot) may become "trapped" before the fetal head during the external version process and end up being the component that gives birth when labor starts.

How Are Compound Presentations Diagnosed?

A vaginal examination is used to make the diagnosis, and in many cases, the problem is not discovered until labor has progressed significantly and the cervix is fully dilated.

One suspects the condition when,

The active phase of labor is moving more slowly than it should.

Engagement does not take place - In any situation where the fetal head does not engage during labor. Still, there is no cephalo-pelvic disproportion (when the baby's head is too large and does not fit into the mother's pelvis), so the compound presentation diagnosis should be considered.

Even after the membranes have ruptured, the fetal head continues to be elevated and off-center during labor.

What Is the Effect of Compound Presentation on Labor?

The size of the fetus and the mother's pelvis affect compound presentation during labor.

There are three possible perspectives on this,

The fetal head may not enter the pelvic brim in cases where the fetus is large, and the pelvis is narrow due to a compound presentation. If it is not fixed, it will cause obstructed labor.

A complex presentation will delay the second stage of labor when the fetus and the pelvis are of average size. This delay results from the prolapsed limb interfering with the fetal head's normal internal and external flexion and rotation mechanisms. Correction is frequently required.

A complex presentation will not change the course of labor if the fetus is small and the pelvis is large; the baby will still be born with the hand prolapsed.

What Is the Treatment of Compound Presentation?

The fetal presentation and position determine how the fetus is positioned in the womb during the delivery. As in all cases of fetal presentation and position, such as a baby in the vertex or face presentation, the first essential is to determine whether the pelvis is large enough to allow vaginal delivery. The baby in vertex position is delivered through the vagina and the doctor will say to the woman to push the baby until the head comes out. Face presentation baby can be delivered through the vagina and in more complicated cases, C-section is indicated. A cesarean section will have to be performed if there is a mechanical obstruction.

If there is no obstruction, a vaginal delivery will be possible following one of the undermentioned methods,

Treatment of the presentation of an arm aims at preventing its prolapse into the vagina when the membranes rupture. Initially, the patient is placed in the genu pectoral or high Trendelenburg position for 30 minutes. This allows the limb, aided by gravity, to slip back above the head. The patient is then placed in the dorsal position. The fetal head is pushed into the pelvic brim by abdominal palpation, and an abdominal binder is applied. This method is not always successful. A vaginal examination should be performed as soon as the membranes rupture.

The prolapse of an arm or foot is best treated by replacing the limb above the head. The head is then pressed down by pressure on the abdomen. It is advisable not to remove the hand from the vagina until the head has been pushed into the pelvis.

When a prolapsed arm is discovered during the second stage of labor, it is sometimes possible to deliver by forceps without replacing the arm. During the application of the forceps, care must be taken not to include the arm within the forceps blades.

The internal version is now rarely used because of the dangers involved. The method may cause separation of the placenta and death of the features, rupture of the uterus, and probable death of the mother.

This method should only be used in the following cases,

An arm prolapses again after replacement.

A foot resists all attempts at replacement.

Occasionally, the compound presentation is complicated by the prolapse of the cord.

Prolapse of the cord necessitates rapid treatment if the fetus is to be saved. In the first stage of labor, a cesarean section is the treatment of choice. During the second stage of labor, forceps delivery is indicated, preferably if conditions permit, without replacement of the limb. The internal version is indicated solely when these procedures are not practical because of a lack of equipment.

What Are the Complications of Compound Presentation?

The two complications likely to occur are prolapse of the umbilical cord and uterine inertia.

They are as follows,

Prolapse of the Umbilical Cord - The same factors that lead to limb prolapse can cause cord prolapse. Most of the time, it will call for immediate delivery.

Inertia - Inertia may complicate any malpresentation. Its exact cause is unknown, but it may be due to the malposition of the fetus interfering with the normal mechanism of labor. The uterus reacts to this interference by diminishing its action. Treatment of inertia usually necessitates replacement of the prolapsed limb, except early in the first stage, when it is sometimes better to treat inertia by recognized methods and later replace the limb.

Conclusion:

In the majority of situations, compound presentation events need not significantly alter the arrangements already made for the method of managing the birth process. Simple stimuli that are intended to encourage the baby to reject the abnormal component may be successful. Following the identification of the invasive portion, labor, and delivery should be managed conservatively and following other established obstetrical standards.

Frequently Asked Questions

How is compound presentation treated, how is compound breech clinically seen, what does icd code 10 in compound presentation represent, is compound presentation normal/vertex, what is meant by cephalic presentation, and is it considered good, how are compound presentation patients delivered, is a cephalic presentation considered ideal in cases of c section, what are the complications of breech position, and can patients with the same have a normal delivery.

Management of Brow, Face, and Compound Malpresentations

https://exxcellence.org/list-of-pearls/management-of-brow-face-and-compound-malpresentations/

Fetus papyraceous disguised as compound presentation: A case report

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9486711/

Compound presentation following external version

https://pubmed.ncbi.nlm.nih.gov/283786/

Obstetrics and Gynecology

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Asynclitism: Clinical and Intrapartum Diagnosis in Labor

Fig. 6.1 Palpation of the fetal sagittal suture, with ­vaginal exploration, in eutocic labor with fetal head synclitic Fig. 6.2 Palpation of the posterior and anterior fontanel of the synclitic fetal head, through the vagina, during eutocic labor When neither of the parietal bones precedes the sagittal suture, the head is synclitic (Fig. 6.3 ). If the anterior parietal bone precedes the sagittal suture, there is an anterior asynclitism (Fig. 6.4 ). When the posterior parietal bone precedes the sagittal suture, there is a posterior asynclitism (Fig. 6.5 ) [ 3 ]. Fig. 6.3 Sagittal section of the pelvis and abdomen in labor with the fetus in cephalic presentation ( a ) in posterior asynclitism, ( b ) in anterior asynclitism Fig. 6.4 Palpation of the fetal head sagittal suture during vaginal digital examination, during labor, in left occiput position, transverse, with anterior asynclitism Fig. 6.5 Palpation of the anterior fontanel via the vaginal digital examination, during labor, in left occiput transverse position, with posterior asynclitism In 1858, Smith [ 2 ] reported that in a left occiput anterior (LOA) position, the right side of the cranium is considerably lower than that of the left, so that the most depending part of the cranial surface is the protuberance of the right parietal bone. This lateral depression was called the “obliquity of the head.” When assessing the fetal head at the level of the pelvic inlet in LOA position, the bulging of the right parietal bone is felt through the walls of the anterior portion of the cervix. This is the point with which the finger comes in contact with the most depending part of the head. If the finger is passed in to the cervical os, the sagittal suture is felt crossing the field of the os in an oblique direction. The sagittal suture divides the os unequally, and a larger portion of the middle and upper part of the right parietal bone is included within the ring of the os more than the left. It is this middle and upper portion of the right parietal bone which is felt in making a vaginal examination at this time. The earlier the digital examination is made, the sagittal suture will be found to be more markedly oblique or approaching the transverse direction. The fetal occiput rotates 45° clockwise (from the fetal point of view) from the oblique diameter at the level of the pelvic inlet to the AP diameter in the mid and lower pelvis in its progression in the birth canal. In emerging form of the pelvis, the obliquity of the head is almost as great as at its entrance, the right parietal bone being still lower than the left. The head does not emerge either with the occipital or parietal protuberance foremost, the part which escapes first being a point between the two, namely, the upper and posterior part of the right parietal bone, named parietal eminence or tuber parietale (Fig. 6.6 ) [ 4 ]. Fig. 6.6 Parietal bone different portion of the outer surface [ 4 ], with permission ( left ). Fetal skulls and fetal head diameters, in the circumference are reported the ­sub-occiput-bregmatic diameter (9,5 centimetres). This diameter to allow the normal engagement of fetal head in the medpelvis, and perform the head asynclitism in distocic labor ( rigth ) Any fetal head position may be associated with asynclitism, and Table 6.1 shows the different kind of asynclitism in all the occiput positions. Table 6.1 The table represents the various forms of asynclitism in the anterior occipital positions of the fetal head To diagnose asynclitism, it is first necessary to determine the position of the fetal occiput with respect to the maternal pelvis. The side to which the occiput is positioned will indicate the laterality of the asynclitism. In an anterior asynclitism, the presenting parietal bone will be opposite to which side it is rotated toward. Conversely, the presenting parietal bone in a posterior asynclitism is the same side to which the occiput is rotated. This holds true regardless of the occiput being positioned anteriorly, posteriorly, or transversely (Fig. 6.7 ). Fig. 6.7 Vaginal digital examination in left occiput transverse with posterior asynclitism. The exploring fingers will palpate the sagittal suture closer to the symphysis Moderate degrees of asynclitism though are the rule in normal labor, and specifically the fetal head in occiput anterior engages with an anterior asynclitism. If it is pronounced enough, it can be responsible of many complications in the maternal and fetal care during the intrapartum period, the most common of which are arrest disorders of the fetal head during descent in the birth canal, even with an otherwise normal size pelvis. The most common etiologies of an excessive ­nonphysiologic asynclitism may be the peculiar maternal bony pelvic anatomy (Fig. 6.8a–c ), the tone of the ­pelvic musculature, and the force and consistency of uterine contractions. During the vaginal digital examination, if the sagittal suture is felt to be curving anteriorly (Naegele’s obliquity, Fig. 6.9a, b ) or posteriorly (Litzmann’s obliquity, Fig. 6.10a–d ), such cranial asymmetry increases the diameter of fetal cranium and can lead to dystocia. Fig. 6.8 ( a ) Posterior asynclitism in the flat basin (or obliquity of Naegale phenomenon), with overlapping of the cranial bones, which is a phenomenon of adaptation to the commitment and progression of the fetal head. ( b ) Sellheim theory according to which an egg-shaped body can pass through a cylinder of a size smaller than its transverse diameter, if it breaks down into two parts which are arranged obliquely. ( c ) The molding phenomenon of fetal cranial bones is well visualized by translabial US, especially in the head up. The overlapping of the cranial bones is a positive sign for the performance prediction of spontaneous delivery Fig. 6.9 ( a ) Ultrasound evaluation of posterior asynclitism with translabial longitudinal section, ( b ) Ultrasound evaluation of posterior asynclitism with transabdominal sagittal section Fig. 6.10 ( a ) Fetal head vertex presentation, in the right occiput transverse position with posterior asynclitism. ( b ) Draw representing ultrasonographic evaluation of fetal posterior asynclitism. ( c ) Ultrasound image of fetal posterior asynclitism: midline ( ML ), thalamus ( TH ), and orbit ( O ). ( d ) Posterior asynclitism in right occipital transverse position, displayed by ultrasound (the thicker line passing through the sagittal suture relative to the small line that indicates the degree of asynclitism) Most of the time anterior asynclitism is not diagnosed unless attention is placed to the hollow of the maternal sacrum [ 5 ]. The posterior pelvis feels empty unless the fetal head is at a low station. Failure of the sacral hollow to be occupied by the fetal head is suggesting of a higher fetal head station than what the initial palpation of the presenting part may suggest. As understandable, the presence of asynclitism becomes a very important factor in the already subjective and unreliable diagnosis of correct fetal head station [ 6 , 7 ]. Generally, diagnosis of asynclitism is made subjectively in an indirect way, i.e., when labor slows down or fetal head progression in the birth canal stops. Ultrasound has recently been used as a more objective tool in supporting and validating the clinical diagnosis of asynclitism [ 8 – 12 ]. Different sonographic approaches including transabdominal, transperineal, and transvaginal, both in 2D and 3D, have been utilized in the determination of fetal position based on such landmark as the fetal orbits, cerebellum, midline echo of the brain, and occiput (Fig. 6.11 ) [ 10 , 13 – 18 ]. Fig. 6.11 Perfect synclitism in left occiput anterior position by transabdominal ultrasound ( panel a ), transperineal ultrasound ( panel b ), and transvaginal ultrasound ( panel c ) 6.2 Asynclitism in the Occiput Posterior (OP) Position The occiput posterior position has been easily diagnosed by ultrasound by both approach, transabdominal and transperineal examinations [ 14 , 18 ]. The orbits are an easily identified marker in the fetal head, and they will be directly under the symphysis in the case of direct OP position (Fig. 6.12 ) or toward the upper portion of the right inferior ramus of the pubis, in left occiput position (LOP) or toward the upper portion of the left inferior ramus of the pubis, and in right occiput position (ROP). If the asynclitism is also present, only one orbit will be visualized by ­ultrasound, the so-called squint sign [ 10 ]. In case of LOP position, the only visualization of the right anterior orbit will be called anterior asynclitism (Fig. 6.13 ), whereas the only visualization of the left posterior orbit will be called posterior asynclitism. The same definitions will be used in case of ROP, where the anterior orbit is the left (Fig. 6.14 ) and the posterior is the right. The OP and OT shows different degrees of asynclitism, anterior or posterior (Fig. 6.15 ) and the “squint sign”, using transabdominal sonography.

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