presentation is unstable at present

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 transverse 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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7 Mental Strategies to Help you Recover from a Presentation Disaster

by Olivia Mitchell | 24 comments

The complaints started within the first half hour of the course:

“I don’t understand what this means”.

“This is too hard for us”.

“This doesn’t work for the presentations that I have to do.”

By the end of the day I was exhausted and dispirited.

At some point in your presenting career something similar may happen to you – your content simply doesn’t land for your audience, your technology breaks down or you don’t get the result you were hoping for.

Here are seven mental strategies to help you recover from a presentation disaster. You’re likely to resonate with some and not others. Choose what works for you.

1. Allow yourself some time to dwell on the disappointment

We live in a society that encourages us to “think positive” all the time. But uncomfortable emotions are a normal part of life. Accepting the disappointment will allow you to let it go more easily and move on. If in the past you’ve stewed about failure in a way that disrupts your life, then give yourself a time limit to experience the disappointment and then use the mental strategies below to help you move on.

2. Practice Self-compassion

We often talk to ourselves in very harsh ways. For example:

“Oh, you’re such a loser. You should have known that somebody was going to ask that question and you should have researched the answer. You came across like a total pillock.”

Can you imagine talking to your best friend like that. No. you’d be more likely to say to them:

“That was a very tricky question that audience member asked. You couldn’t have predicted that. And you did your best to answer it.”

Talk to yourself like you would talk to your best friend.

3. It doesn’t mean anything about you

It’s easy when it comes to a disastrous presentation to conclude that you are the disaster, that you’re incompetent and unworthy.

But this is not the case.

My husband Tony used to do some amateur acting and so had the experience of repeating the same play with the exact same script several days in a row. Some nights the audience expressed their enjoyment and appreciation loudly, some nights nothing. Exact same script, exact same performance. Different audience.

Coming back to your presentation, it could simply be the audience. But even if it was your content that was wrong, or your technology that broke down, your presentation disaster doesn’t mean anything about you as a person.

4. Put it into perspective

There are two ways of doing this:

• Imagine yourself 10 years from now. How will you feel then about this presentation? Will you even remember it?
• How disastrous is this presentation compared to other things in your life that have gone wrong or could go wrong? Your health or the health of a loved one? A breakdown of a relationship? Most disastrous presentations are not that bad.

5. Look for the silver lining

Whenever something goes wrong with a presentation, it’s an opportunity to work out why it went wrong, and to improve how you do things next time you present. For example, with my experience with the confused course participants I could look for how to make the material clearer and how to pre-empt participant concerns before they happened.

6. Who knows whether it’s good or bad

Humans are great at making meaning. As soon as an event happens, we’ll evaluate it and slap a label on it – good or bad.

You may have come across the classic story from the Chinese Taoist tradition about a farmer and his horse:

One day his horse runs away. And his neighbor comes over and says, to commiserate, “I’m so sorry about your horse.” And the farmer says “Who Knows What’s Good or Bad?” The neighbor is confused because this is clearly terrible. The horse is the most valuable thing he owns. But the horse comes back the next day and he brings with him 12 feral horses. The neighbor comes back over to celebrate, “Congratulations on your great fortune!” And the farmer replies again: “Who Knows What’s Good or Bad?” And the next day the farmer’s son is taming one of the wild horses and he’s thrown and breaks his leg. The neighbor comes back over, “I’m so sorry about your son.” The farmer repeats: “Who Knows What’s Good or Bad?” Sure enough, the next day the army comes through their village and is conscripting able-bodied young men to go and fight in war, but the son is spared because of his broken leg.

This story can go on forever, alternating between events which seem good, and those that seem bad.

In this spirit, you don’t know whether this disastrous presentation is good or bad. In fact…

7. Devastating failure often sets the stage for later success

“What’s failure in your life that has set the stage for a later success?”

The answers to this question are mind blowing. Some of these people suffered devastating professional failures which contributed directly to stunning achievements.

Use these strategies next time you have a disappointing experience with a presentation. And let me know what strategies you’ve found useful to recover from a presentation disaster.

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24 Comments

Great tips, Olivia. I really like the ones about self-compassion and perspective. So true. (And I’d not heard the horse story before – that’s a good way of looking at life!)

Thank you Craig

The story of man and horse not only suitable for presentation disaster but also it gives us a life lesson.Thank you Olivia for the support.

Absolutely Jeena, and most of the strategies in my post can be applied to our life challenges as well.

Please unsubscribe me. There is a legal obligation to provide this option- don’t see a link fir unsubscribe. Thanks

Clear link at bottom of email…?

Hi Finola, I have unsubscribed you. My emails are sent through a professional email provider that provides an unsubscribe link at the bottom of every email, so not sure what happened there. Olivia

Russian greatest poet Alexander Pushkin wrote poetry about 200 years ago. Here are original and translated versions: ?, ??????? ??? ???????? ?????? ??????? ??????????? ??? ? ???? – ??? ?????? ???????, ? ????? – ?????????? ????, ? ?????? – ???-????????????…

How many blissful revelations The spirit of enlightment hides! And then experience born of lapses And genius antinomy-wise And chance, the heavenly inventor…

Thank you Marcel, that is quite beautiful.

Awesome tips. I feel much better. Thank you!

It seems Russian language too difficult for this site even to dispaly))

Will Smith posted motivational speech recently about role of a failure in our life https://www.youtube.com/watch?v=wFf6rhcYkXw

Great message in that video.

Olivia thank you so much for boosting my courage on public speaking, I’m doing better now.

Yay Emmy! That’s great to hear. So pleased for you :-).

wow, thanks so much. I can’t wait to try again

“Who Knows What’s Good or Bad?”.This did it for me, was feeling awful about my presentation. Thank you.

Hi Olivia. Hope you have a good day. I really appreciate this writing. I am undergraduate students and just now my groupmate presentation get a lot of critics from my lecturer thus, as a leader I feel sad to see them with their slides being ignored just like that. I totally blame myself because I was the one who divided what parts they should do and what they should write because they said they just will go with my planned. Although, they didn’t blame me and apologize for their mistakes in the writing and slides, I still feel it was my fault. It is not easy to cope with this feeling but somehow your writing help me to go through it. Thank you so much.

This was very helpful! I feel much better. Thanks.

My husband left me heartbroken for 6 months. After i came in contact with R.buckler11 @ gmail [.] com, my Husband came back quickly. Keep up the good work …………

I think it’s important for kids to learn how to deal with and understand their emotions from an early age since doing so will help them avoid many difficult situations in the future. Healthy relationships are the cornerstone of positive well-being, which is why I have singled out for myself a relationship counselors online https://ca.calmerry.com/relationship-counseling/ where you can find relationship counselors online. Any relationship issues that are lowering one’s quality of life can be resolved with the help of relationship therapy or counseling.

What physical or emotional symptoms of stress do you notice in yourself, and how do you try to manage them to keep yourself healthy?

Thank you for sharing these invaluable strategies for navigating presentation mishaps. It’s comforting to know there are ways to bounce back from challenging moments during public speaking. Allowing ourselves to acknowledge and process disappointment is crucial, as you rightly pointed out. Sometimes, we’re urged to embrace positivity constantly, but acknowledging and experiencing those uncomfortable emotions is a natural wellness center part of our journey. Setting a limit on dwelling allows for a healthier transition to moving forward.

In an effort to maintain one’s health, which physical or emotional manifestations of stress do you personally observe and how do you attempt to regulate them?

Unfortunately, mental disorders in young people are not at all uncommon. However, the cannabis industry now has a variety of products, such as CBD, for treating mental disorders. I’m not young anymore and to relieve stress I use these https://westcoastbud.io/ cannabis concentrates in small doses and it gives excellent results. I advise you to pay attention to this site.

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• Would you talk to a friend the way you talk to yourself?
• Does it make sense that if you changed the way you talked to yourself, you could reduce your fear of public speaking?

I will show you exactly how in this free video training series and workbook.

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How To Make a Good Presentation [A Complete Guide]

By Krystle Wong , Jul 20, 2023

A top-notch presentation possesses the power to drive action. From winning stakeholders over and conveying a powerful message to securing funding — your secret weapon lies within the realm of creating an effective presentation .  

Being an excellent presenter isn’t confined to the boardroom. Whether you’re delivering a presentation at work, pursuing an academic career, involved in a non-profit organization or even a student, nailing the presentation game is a game-changer.

In this article, I’ll cover the top qualities of compelling presentations and walk you through a step-by-step guide on how to give a good presentation. Here’s a little tip to kick things off: for a headstart, check out Venngage’s collection of free presentation templates . They are fully customizable, and the best part is you don’t need professional design skills to make them shine!

These valuable presentation tips cater to individuals from diverse professional backgrounds, encompassing business professionals, sales and marketing teams, educators, trainers, students, researchers, non-profit organizations, public speakers and presenters. 

No matter your field or role, these tips for presenting will equip you with the skills to deliver effective presentations that leave a lasting impression on any audience.

Click to jump ahead:

What are the 10 qualities of a good presentation?

Step-by-step guide on how to prepare an effective presentation, 9 effective techniques to deliver a memorable presentation, faqs on making a good presentation, how to create a presentation with venngage in 5 steps.

When it comes to giving an engaging presentation that leaves a lasting impression, it’s not just about the content — it’s also about how you deliver it. Wondering what makes a good presentation? Well, the best presentations I’ve seen consistently exhibit these 10 qualities:

1. Clear structure

No one likes to get lost in a maze of information. Organize your thoughts into a logical flow, complete with an introduction, main points and a solid conclusion. A structured presentation helps your audience follow along effortlessly, leaving them with a sense of satisfaction at the end.

Regardless of your presentation style , a quality presentation starts with a clear roadmap. Browse through Venngage’s template library and select a presentation template that aligns with your content and presentation goals. Here’s a good presentation example template with a logical layout that includes sections for the introduction, main points, supporting information and a conclusion: 

2. Engaging opening

Hook your audience right from the start with an attention-grabbing statement, a fascinating question or maybe even a captivating anecdote. Set the stage for a killer presentation!

The opening moments of your presentation hold immense power – check out these 15 ways to start a presentation to set the stage and captivate your audience.

3. Relevant content

Make sure your content aligns with their interests and needs. Your audience is there for a reason, and that’s to get valuable insights. Avoid fluff and get straight to the point, your audience will be genuinely excited.

4. Effective visual aids

Picture this: a slide with walls of text and tiny charts, yawn! Visual aids should be just that—aiding your presentation. Opt for clear and visually appealing slides, engaging images and informative charts that add value and help reinforce your message.

With Venngage, visualizing data takes no effort at all. You can import data from CSV or Google Sheets seamlessly and create stunning charts, graphs and icon stories effortlessly to showcase your data in a captivating and impactful way.

5. Clear and concise communication

Keep your language simple, and avoid jargon or complicated terms. Communicate your ideas clearly, so your audience can easily grasp and retain the information being conveyed. This can prevent confusion and enhance the overall effectiveness of the message. 

6. Engaging delivery

Spice up your presentation with a sprinkle of enthusiasm! Maintain eye contact, use expressive gestures and vary your tone of voice to keep your audience glued to the edge of their seats. A touch of charisma goes a long way!

7. Interaction and audience engagement

Turn your presentation into an interactive experience — encourage questions, foster discussions and maybe even throw in a fun activity. Engaged audiences are more likely to remember and embrace your message.

Transform your slides into an interactive presentation with Venngage’s dynamic features like pop-ups, clickable icons and animated elements. Engage your audience with interactive content that lets them explore and interact with your presentation for a truly immersive experience.

8. Effective storytelling

Who doesn’t love a good story? Weaving relevant anecdotes, case studies or even a personal story into your presentation can captivate your audience and create a lasting impact. Stories build connections and make your message memorable.

A great presentation background is also essential as it sets the tone, creates visual interest and reinforces your message. Enhance the overall aesthetics of your presentation with these 15 presentation background examples and captivate your audience’s attention.

9. Well-timed pacing

Pace your presentation thoughtfully with well-designed presentation slides, neither rushing through nor dragging it out. Respect your audience’s time and ensure you cover all the essential points without losing their interest.

10. Strong conclusion

Last impressions linger! Summarize your main points and leave your audience with a clear takeaway. End your presentation with a bang , a call to action or an inspiring thought that resonates long after the conclusion.

In-person presentations aside, acing a virtual presentation is of paramount importance in today’s digital world. Check out this guide to learn how you can adapt your in-person presentations into virtual presentations . 

Preparing an effective presentation starts with laying a strong foundation that goes beyond just creating slides and notes. One of the quickest and best ways to make a presentation would be with the help of a good presentation software . 

Otherwise, let me walk you to how to prepare for a presentation step by step and unlock the secrets of crafting a professional presentation that sets you apart.

1. Understand the audience and their needs

Before you dive into preparing your masterpiece, take a moment to get to know your target audience. Tailor your presentation to meet their needs and expectations , and you’ll have them hooked from the start!

2. Conduct thorough research on the topic

Time to hit the books (or the internet)! Don’t skimp on the research with your presentation materials — dive deep into the subject matter and gather valuable insights . The more you know, the more confident you’ll feel in delivering your presentation.

3. Organize the content with a clear structure

No one wants to stumble through a chaotic mess of information. Outline your presentation with a clear and logical flow. Start with a captivating introduction, follow up with main points that build on each other and wrap it up with a powerful conclusion that leaves a lasting impression.

Delivering an effective business presentation hinges on captivating your audience, and Venngage’s professionally designed business presentation templates are tailor-made for this purpose. With thoughtfully structured layouts, these templates enhance your message’s clarity and coherence, ensuring a memorable and engaging experience for your audience members.

Don’t want to build your presentation layout from scratch? pick from these 5 foolproof presentation layout ideas that won’t go wrong. 

4. Develop visually appealing and supportive visual aids

Spice up your presentation with eye-catching visuals! Create slides that complement your message, not overshadow it. Remember, a picture is worth a thousand words, but that doesn’t mean you need to overload your slides with text.

Well-chosen designs create a cohesive and professional look, capturing your audience’s attention and enhancing the overall effectiveness of your message. Here’s a list of carefully curated PowerPoint presentation templates and great background graphics that will significantly influence the visual appeal and engagement of your presentation.

5. Practice, practice and practice

Practice makes perfect — rehearse your presentation and arrive early to your presentation to help overcome stage fright. Familiarity with your material will boost your presentation skills and help you handle curveballs with ease.

6. Seek feedback and make necessary adjustments

Don’t be afraid to ask for help and seek feedback from friends and colleagues. Constructive criticism can help you identify blind spots and fine-tune your presentation to perfection.

With Venngage’s real-time collaboration feature , receiving feedback and editing your presentation is a seamless process. Group members can access and work on the presentation simultaneously and edit content side by side in real-time. Changes will be reflected immediately to the entire team, promoting seamless teamwork.

7. Prepare for potential technical or logistical issues

Prepare for the unexpected by checking your equipment, internet connection and any other potential hiccups. If you’re worried that you’ll miss out on any important points, you could always have note cards prepared. Remember to remain focused and rehearse potential answers to anticipated questions.

8. Fine-tune and polish your presentation

As the big day approaches, give your presentation one last shine. Review your talking points, practice how to present a presentation and make any final tweaks. Deep breaths — you’re on the brink of delivering a successful presentation!

In competitive environments, persuasive presentations set individuals and organizations apart. To brush up on your presentation skills, read these guides on how to make a persuasive presentation and tips to presenting effectively . 

Whether you’re an experienced presenter or a novice, the right techniques will let your presentation skills soar to new heights!

From public speaking hacks to interactive elements and storytelling prowess, these 9 effective presentation techniques will empower you to leave a lasting impression on your audience and make your presentations unforgettable.

1. Confidence and positive body language

Positive body language instantly captivates your audience, making them believe in your message as much as you do. Strengthen your stage presence and own that stage like it’s your second home! Stand tall, shoulders back and exude confidence. 

2. Eye contact with the audience

Break down that invisible barrier and connect with your audience through their eyes. Maintaining eye contact when giving a presentation builds trust and shows that you’re present and engaged with them.

3. Effective use of hand gestures and movement

A little movement goes a long way! Emphasize key points with purposeful gestures and don’t be afraid to walk around the stage. Your energy will be contagious!

4. Utilize storytelling techniques

Weave the magic of storytelling into your presentation. Share relatable anecdotes, inspiring success stories or even personal experiences that tug at the heartstrings of your audience. Adjust your pitch, pace and volume to match the emotions and intensity of the story. Varying your speaking voice adds depth and enhances your stage presence.

5. Incorporate multimedia elements

Spice up your presentation with a dash of visual pizzazz! Use slides, images and video clips to add depth and clarity to your message. Just remember, less is more—don’t overwhelm them with information overload. 

Turn your presentations into an interactive party! Involve your audience with questions, polls or group activities. When they actively participate, they become invested in your presentation’s success. Bring your design to life with animated elements. Venngage allows you to apply animations to icons, images and text to create dynamic and engaging visual content.

6. Utilize humor strategically

Laughter is the best medicine—and a fantastic presentation enhancer! A well-placed joke or lighthearted moment can break the ice and create a warm atmosphere , making your audience more receptive to your message.

7. Practice active listening and respond to feedback

Be attentive to your audience’s reactions and feedback. If they have questions or concerns, address them with genuine interest and respect. Your responsiveness builds rapport and shows that you genuinely care about their experience.

8. Apply the 10-20-30 rule

Apply the 10-20-30 presentation rule and keep it short, sweet and impactful! Stick to ten slides, deliver your presentation within 20 minutes and use a 30-point font to ensure clarity and focus. Less is more, and your audience will thank you for it!

9. Implement the 5-5-5 rule

Simplicity is key. Limit each slide to five bullet points, with only five words per bullet point and allow each slide to remain visible for about five seconds. This rule keeps your presentation concise and prevents information overload.

Simple presentations are more engaging because they are easier to follow. Summarize your presentations and keep them simple with Venngage’s gallery of simple presentation templates and ensure that your message is delivered effectively across your audience.

1. How to start a presentation?

To kick off your presentation effectively, begin with an attention-grabbing statement or a powerful quote. Introduce yourself, establish credibility and clearly state the purpose and relevance of your presentation.

2. How to end a presentation?

For a strong conclusion, summarize your talking points and key takeaways. End with a compelling call to action or a thought-provoking question and remember to thank your audience and invite any final questions or interactions.

3. How to make a presentation interactive?

To make your presentation interactive, encourage questions and discussion throughout your talk. Utilize multimedia elements like videos or images and consider including polls, quizzes or group activities to actively involve your audience.

In need of inspiration for your next presentation? I’ve got your back! Pick from these 120+ presentation ideas, topics and examples to get started. 

Creating a stunning presentation with Venngage is a breeze with our user-friendly drag-and-drop editor and professionally designed templates for all your communication needs. 

Here’s how to make a presentation in just 5 simple steps with the help of Venngage:

Step 1: Sign up for Venngage for free using your email, Gmail or Facebook account or simply log in to access your account. 

Step 2: Pick a design from our selection of free presentation templates (they’re all created by our expert in-house designers).

Step 3: Make the template your own by customizing it to fit your content and branding. With Venngage’s intuitive drag-and-drop editor, you can easily modify text, change colors and adjust the layout to create a unique and eye-catching design.

Step 4: Elevate your presentation by incorporating captivating visuals. You can upload your images or choose from Venngage’s vast library of high-quality photos, icons and illustrations. 

Step 5: Upgrade to a premium or business account to export your presentation in PDF and print it for in-person presentations or share it digitally for free!

By following these five simple steps, you’ll have a professionally designed and visually engaging presentation ready in no time. With Venngage’s user-friendly platform, your presentation is sure to make a lasting impression. So, let your creativity flow and get ready to shine in your next presentation!

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What It Takes to Give a Great Presentation

• Carmine Gallo

Five tips to set yourself apart.

Never underestimate the power of great communication. It can help you land the job of your dreams, attract investors to back your idea, or elevate your stature within your organization. But while there are plenty of good speakers in the world, you can set yourself apart out by being the person who can deliver something great over and over. Here are a few tips for business professionals who want to move from being good speakers to great ones: be concise (the fewer words, the better); never use bullet points (photos and images paired together are more memorable); don’t underestimate the power of your voice (raise and lower it for emphasis); give your audience something extra (unexpected moments will grab their attention); rehearse (the best speakers are the best because they practice — a lot).

I was sitting across the table from a Silicon Valley CEO who had pioneered a technology that touches many of our lives — the flash memory that stores data on smartphones, digital cameras, and computers. He was a frequent guest on CNBC and had been delivering business presentations for at least 20 years before we met. And yet, the CEO wanted to sharpen his public speaking skills.

• Carmine Gallo is a Harvard University instructor, keynote speaker, and author of 10 books translated into 40 languages. Gallo is the author of The Bezos Blueprint: Communication Secrets of the World’s Greatest Salesman  (St. Martin’s Press).

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Malpresentations and malpositions

Peer reviewed by Dr Laurence Knott Last updated by Dr Colin Tidy, MRCGP Last updated 22 Jun 2021

Meets Patient’s editorial guidelines

Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our  health articles  more useful.

In this article :

Malpresentation, malposition.

Usually the fetal head engages in the occipito-anterior position (more often left occipito-anterior (LOA) rather than right) and then undergoes a short rotation to be directly occipito-anterior in the mid-cavity. Malpositions are abnormal positions of the vertex of the fetal head relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex.

Obstetrics - the pelvis and head

Continue reading below

Predisposing factors to malpresentation include:

Prematurity.

Multiple pregnancy.

Abnormalities of the uterus - eg, fibroids.

Partial septate uterus.

Abnormal fetus.

Placenta praevia.

Primiparity.

Breech presentation

See the separate Breech Presentations article for more detailed discussion.

Breech presentation is the most common malpresentation, with the majority discovered before labour. Breech presentation is much more common in premature labour.

Approximately one third are diagnosed during labour when the fetus can be directly palpated through the cervix.

After 37 weeks, external cephalic version can be attempted whereby an attempt is made to turn the baby manually by manipulating the pregnant mother's abdomen. This reduces the risk of non-cephalic delivery 1 .

Maternal postural techniques have also been tried but there is insufficient evidence to support these 2 .

Many women who have a breech presentation can deliver vaginally. Factors which make this less likely to be successful include 3 :

Hyperextended neck on ultrasound.

High estimated fetal weight (more than 3.8 kg).

Low estimated weight (less than tenth centile).

Footling presentation.

Evidence of antenatal fetal compromise.

Transverse lie 4

When the fetus is positioned with the head on one side of the pelvis and the buttocks in the other (transverse lie), vaginal delivery is impossible.

This requires caesarean section unless it converts or is converted late in pregnancy. The surgeon may be able to rotate the fetus through the wall of the uterus once the abdominal wall has been opened. Otherwise, a transverse uterine incision is needed to gain access to a fetal pole.

Internal podalic version is no longer attempted.

Transverse lie is associated with a risk of cord prolapse of up to 20%.

Occipito-posterior position

This is the most common malposition where the head initially engages normally but then the occiput rotates posteriorly rather than anteriorly. 5.2% of deliveries are persistent occipito-posterior 5 .

The occipito-posterior position results from a poorly flexed vertex. The anterior fontanelle (four radiating sutures) is felt anteriorly. The posterior fontanelle (three radiating sutures) may also be palpable posteriorly.

It may occur because of a flat sacrum, poorly flexed head or weak uterine contractions which may not push the head down into the pelvis with sufficient strength to produce correct rotation.

As occipito-posterior-position pregnancies often result in a long labour, close maternal and fetal monitoring are required. An epidural is often recommended and it is essential that adequate fluids be given to the mother.

The mother may get the urge to push before full dilatation but this must be discouraged. If the head comes into a face-to-pubis position then vaginal delivery is possible as long as there is a reasonable pelvic size. Otherwise, forceps or caesarean section may be required.

Occipito-transverse position

The head initially engages correctly but fails to rotate and remains in a transverse position.

Alternatives for delivery include manual rotation of fetal head using Kielland's forceps, or delivery using vacuum extraction. This is inappropriate if there is any fetal acidosis because of the risk of cerebral haemorrhage.

Therefore, there must be provision for a failure of forceps delivery to be changed immediately to a caesarean. The trial of forceps is therefore often performed in theatre. Some centres prefer to manage by caesarean section without trial of forceps.

Face presentations

Face presents for delivery if there is complete extension of the fetal head.

Face presentation occurs in 1 in 1,000 deliveries 5 .

With adequate pelvic size, and rotation of the head to the mento-anterior position, vaginal delivery should be achieved after a long labour.

Backwards rotation of the head to a mento-posterior position requires a caesarean section.

Brow positions

The fetal head stays between full extension and full flexion so that the biggest diameter (the mento-vertex) presents.

Brow presentation occurs in 0.14% of deliveries 5 .

Brow presentation is usually only diagnosed once labour is well established.

The anterior fontanelle and super orbital ridges are palpable on vaginal examination.

Unless the head flexes, a vaginal delivery is not possible, and a caesarean section is required.

Further reading and references

• Hofmeyr GJ, Kulier R, West HM ; External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015 Apr 1;(4):CD000083. doi: 10.1002/14651858.CD000083.pub3.
• Hofmeyr GJ, Kulier R ; Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012 Oct 17;10:CD000051. doi: 10.1002/14651858.CD000051.pub2.
• Management of Breech Presentation ; Royal College of Obstetricians and Gynaecologists (Mar 2017)
• Szaboova R, Sankaran S, Harding K, et al ; PLD.23 Management of transverse and unstable lie at term. Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A112-3. doi: 10.1136/archdischild-2014-306576.324.
• Gardberg M, Leonova Y, Laakkonen E ; Malpresentations - impact on mode of delivery. Acta Obstet Gynecol Scand. 2011 May;90(5):540-2. doi: 10.1111/j.1600-0412.2011.01105.x.

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The information on this page is written and peer reviewed by qualified clinicians.

Next review due: 21 Jun 2026

22 jun 2021 | latest version.

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How to Structure your Presentation, with Examples

August 3, 2018 - Dom Barnard

For many people the thought of delivering a presentation is a daunting task and brings about a  great deal of nerves . However, if you take some time to understand how effective presentations are structured and then apply this structure to your own presentation, you’ll appear much more confident and relaxed.

Here is our complete guide for structuring your presentation, with examples at the end of the article to demonstrate these points.

Why is structuring a presentation so important?

If you’ve ever sat through a great presentation, you’ll have left feeling either inspired or informed on a given topic. This isn’t because the speaker was the most knowledgeable or motivating person in the world. Instead, it’s because they know how to structure presentations – they have crafted their message in a logical and simple way that has allowed the audience can keep up with them and take away key messages.

Research has supported this, with studies showing that audiences retain structured information  40% more accurately  than unstructured information.

In fact, not only is structuring a presentation important for the benefit of the audience’s understanding, it’s also important for you as the speaker. A good structure helps you remain calm, stay on topic, and avoid any awkward silences.

What will affect your presentation structure?

Generally speaking, there is a natural flow that any decent presentation will follow which we will go into shortly. However, you should be aware that all presentation structures will be different in their own unique way and this will be due to a number of factors, including:

• Whether you need to deliver any demonstrations
• How  knowledgeable the audience  already is on the given subject
• How much interaction you want from the audience
• Any time constraints there are for your talk
• What setting you are in
• Your ability to use any kinds of visual assistance

Before choosing the presentation’s structure answer these questions first:

• What is your presentation’s aim?
• Who are the audience?
• What are the main points your audience should remember afterwards?

When reading the points below, think critically about what things may cause your presentation structure to be slightly different. You can add in certain elements and add more focus to certain moments if that works better for your speech.

What is the typical presentation structure?

This is the usual flow of a presentation, which covers all the vital sections and is a good starting point for yours. It allows your audience to easily follow along and sets out a solid structure you can add your content to.

1. Greet the audience and introduce yourself

Before you start delivering your talk, introduce yourself to the audience and clarify who you are and your relevant expertise. This does not need to be long or incredibly detailed, but will help build an immediate relationship between you and the audience. It gives you the chance to briefly clarify your expertise and why you are worth listening to. This will help establish your ethos so the audience will trust you more and think you’re credible.

Read our tips on  How to Start a Presentation Effectively

2. Introduction

In the introduction you need to explain the subject and purpose of your presentation whilst gaining the audience’s interest and confidence. It’s sometimes helpful to think of your introduction as funnel-shaped to help filter down your topic:

• Introduce your general topic
• Explain your topic area
• State the issues/challenges in this area you will be exploring
• State your presentation’s purpose – this is the basis of your presentation so ensure that you provide a statement explaining how the topic will be treated, for example, “I will argue that…” or maybe you will “compare”, “analyse”, “evaluate”, “describe” etc.
• Provide a statement of what you’re hoping the outcome of the presentation will be, for example, “I’m hoping this will be provide you with…”
• Show a preview of the organisation of your presentation

In this section also explain:

• The length of the talk.
• Signal whether you want audience interaction – some presenters prefer the audience to ask questions throughout whereas others allocate a specific section for this.
• If it applies, inform the audience whether to take notes or whether you will be providing handouts.

The way you structure your introduction can depend on the amount of time you have been given to present: a  sales pitch  may consist of a quick presentation so you may begin with your conclusion and then provide the evidence. Conversely, a speaker presenting their idea for change in the world would be better suited to start with the evidence and then conclude what this means for the audience.

Keep in mind that the main aim of the introduction is to grab the audience’s attention and connect with them.

3. The main body of your talk

The main body of your talk needs to meet the promises you made in the introduction. Depending on the nature of your presentation, clearly segment the different topics you will be discussing, and then work your way through them one at a time – it’s important for everything to be organised logically for the audience to fully understand. There are many different ways to organise your main points, such as, by priority, theme, chronologically etc.

• Main points should be addressed one by one with supporting evidence and examples.
• Before moving on to the next point you should provide a mini-summary.
• Links should be clearly stated between ideas and you must make it clear when you’re moving onto the next point.
• Allow time for people to take relevant notes and stick to the topics you have prepared beforehand rather than straying too far off topic.

When planning your presentation write a list of main points you want to make and ask yourself “What I am telling the audience? What should they understand from this?” refining your answers this way will help you produce clear messages.

4. Conclusion

In presentations the conclusion is frequently underdeveloped and lacks purpose which is a shame as it’s the best place to reinforce your messages. Typically, your presentation has a specific goal – that could be to convert a number of the audience members into customers, lead to a certain number of enquiries to make people knowledgeable on specific key points, or to motivate them towards a shared goal.

Regardless of what that goal is, be sure to summarise your main points and their implications. This clarifies the overall purpose of your talk and reinforces your reason for being there.

Follow these steps:

• Signal that it’s nearly the end of your presentation, for example, “As we wrap up/as we wind down the talk…”
• Restate the topic and purpose of your presentation – “In this speech I wanted to compare…”
• Summarise the main points, including their implications and conclusions
• Indicate what is next/a call to action/a thought-provoking takeaway
• Move on to the last section

5. Thank the audience and invite questions

Conclude your talk by thanking the audience for their time and invite them to  ask any questions  they may have. As mentioned earlier, personal circumstances will affect the structure of your presentation.

Many presenters prefer to make the Q&A session the key part of their talk and try to speed through the main body of the presentation. This is totally fine, but it is still best to focus on delivering some sort of initial presentation to set the tone and topics for discussion in the Q&A.

Other common presentation structures

The above was a description of a basic presentation, here are some more specific presentation layouts:

Demonstration

Use the demonstration structure when you have something useful to show. This is usually used when you want to show how a product works. Steve Jobs frequently used this technique in his presentations.

• Explain why the product is valuable.
• Describe why the product is necessary.
• Explain what problems it can solve for the audience.
• Demonstrate the product  to support what you’ve been saying.
• Make suggestions of other things it can do to make the audience curious.

Problem-solution

This structure is particularly useful in persuading the audience.

• Briefly frame the issue.
• Go into the issue in detail showing why it ‘s such a problem. Use logos and pathos for this – the logical and emotional appeals.
• Provide the solution and explain why this would also help the audience.
• Call to action – something you want the audience to do which is straightforward and pertinent to the solution.

Storytelling

As well as incorporating  stories in your presentation , you can organise your whole presentation as a story. There are lots of different type of story structures you can use – a popular choice is the monomyth – the hero’s journey. In a monomyth, a hero goes on a difficult journey or takes on a challenge – they move from the familiar into the unknown. After facing obstacles and ultimately succeeding the hero returns home, transformed and with newfound wisdom.

Storytelling for Business Success  webinar , where well-know storyteller Javier Bernad shares strategies for crafting compelling narratives.

Another popular choice for using a story to structure your presentation is in media ras (in the middle of thing). In this type of story you launch right into the action by providing a snippet/teaser of what’s happening and then you start explaining the events that led to that event. This is engaging because you’re starting your story at the most exciting part which will make the audience curious – they’ll want to know how you got there.

• Great storytelling: Examples from Alibaba Founder, Jack Ma

Remaining method

The remaining method structure is good for situations where you’re presenting your perspective on a controversial topic which has split people’s opinions.

• Go into the issue in detail showing why it’s such a problem – use logos and pathos.
• Rebut your opponents’ solutions  – explain why their solutions could be useful because the audience will see this as fair and will therefore think you’re trustworthy, and then explain why you think these solutions are not valid.
• After you’ve presented all the alternatives provide your solution, the remaining solution. This is very persuasive because it looks like the winning idea, especially with the audience believing that you’re fair and trustworthy.

Transitions

When delivering presentations it’s important for your words and ideas to flow so your audience can understand how everything links together and why it’s all relevant. This can be done  using speech transitions  which are words and phrases that allow you to smoothly move from one point to another so that your speech flows and your presentation is unified.

Transitions can be one word, a phrase or a full sentence – there are many different forms, here are some examples:

Moving from the introduction to the first point

Signify to the audience that you will now begin discussing the first main point:

• Now that you’re aware of the overview, let’s begin with…
• First, let’s begin with…
• I will first cover…
• My first point covers…
• To get started, let’s look at…

Shifting between similar points

Move from one point to a similar one:

• In the same way…
• Likewise…
• Equally…
• This is similar to…
• Similarly…

Internal summaries

Internal summarising consists of summarising before moving on to the next point. You must inform the audience:

• What part of the presentation you covered – “In the first part of this speech we’ve covered…”
• What the key points were – “Precisely how…”
• How this links in with the overall presentation – “So that’s the context…”
• What you’re moving on to – “Now I’d like to move on to the second part of presentation which looks at…”

Physical movement

You can move your body and your standing location when you transition to another point. The audience find it easier to follow your presentation and movement will increase their interest.

A common technique for incorporating movement into your presentation is to:

• Start your introduction by standing in the centre of the stage.
• For your first point you stand on the left side of the stage.
• You discuss your second point from the centre again.
• You stand on the right side of the stage for your third point.
• The conclusion occurs in the centre.

Key slides for your presentation

Slides are a useful tool for most presentations: they can greatly assist in the delivery of your message and help the audience follow along with what you are saying. Key slides include:

• An intro slide outlining your ideas
• A  summary slide  with core points to remember
• High quality image slides to supplement what you are saying

There are some presenters who choose not to use slides at all, though this is more of a rarity. Slides can be a powerful tool if used properly, but the problem is that many fail to do just that. Here are some golden rules to follow when using slides in a presentation:

• Don’t over fill them  – your slides are there to assist your speech, rather than be the focal point. They should have as little information as possible, to avoid distracting people from your talk.
• A picture says a thousand words  – instead of filling a slide with text, instead, focus on one or two images or diagrams to help support and explain the point you are discussing at that time.
• Make them readable  – depending on the size of your audience, some may not be able to see small text or images, so make everything large enough to fill the space.
• Don’t rush through slides  – give the audience enough time to digest each slide.

Guy Kawasaki, an entrepreneur and author, suggests that slideshows should follow a  10-20-30 rule :

• There should be a maximum of 10 slides – people rarely remember more than one concept afterwards so there’s no point overwhelming them with unnecessary information.
• The presentation should last no longer than 20 minutes as this will leave time for questions and discussion.
• The font size should be a minimum of 30pt because the audience reads faster than you talk so less information on the slides means that there is less chance of the audience being distracted.

Here are some additional resources for slide design:

• 7 design tips for effective, beautiful PowerPoint presentations
• 11 design tips for beautiful presentations
• 10 tips on how to make slides that communicate your idea

Group Presentations

Group presentations are structured in the same way as presentations with one speaker but usually require more rehearsal and practices.  Clean transitioning between speakers  is very important in producing a presentation that flows well. One way of doing this consists of:

• Briefly recap on what you covered in your section: “So that was a brief introduction on what health anxiety is and how it can affect somebody”
• Introduce the next speaker in the team and explain what they will discuss: “Now Elnaz will talk about the prevalence of health anxiety.”
• Then end by looking at the next speaker, gesturing towards them and saying their name: “Elnaz”.
• The next speaker should acknowledge this with a quick: “Thank you Joe.”

From this example you can see how the different sections of the presentations link which makes it easier for the audience to follow and remain engaged.

Example of great presentation structure and delivery

Having examples of great presentations will help inspire your own structures, here are a few such examples, each unique and inspiring in their own way.

How Google Works – by Eric Schmidt

This presentation by ex-Google CEO  Eric Schmidt  demonstrates some of the most important lessons he and his team have learnt with regards to working with some of the most talented individuals they hired. The simplistic yet cohesive style of all of the slides is something to be appreciated. They are relatively straightforward, yet add power and clarity to the narrative of the presentation.

Start with why – by Simon Sinek

Since being released in 2009, this presentation has been viewed almost four million times all around the world. The message itself is very powerful, however, it’s not an idea that hasn’t been heard before. What makes this presentation so powerful is the simple message he is getting across, and the straightforward and understandable manner in which he delivers it. Also note that he doesn’t use any slides, just a whiteboard where he creates a simple diagram of his opinion.

The Wisdom of a Third Grade Dropout – by Rick Rigsby

Here’s an example of a presentation given by a relatively unknown individual looking to inspire the next generation of graduates. Rick’s presentation is unique in many ways compared to the two above. Notably, he uses no visual prompts and includes a great deal of humour.

However, what is similar is the structure he uses. He first introduces his message that the wisest man he knew was a third-grade dropout. He then proceeds to deliver his main body of argument, and in the end, concludes with his message. This powerful speech keeps the viewer engaged throughout, through a mixture of heart-warming sentiment, powerful life advice and engaging humour.

As you can see from the examples above, and as it has been expressed throughout, a great presentation structure means analysing the core message of your presentation. Decide on a key message you want to impart the audience with, and then craft an engaging way of delivering it.

By preparing a solid structure, and  practising your talk  beforehand, you can walk into the presentation with confidence and deliver a meaningful message to an interested audience.

It’s important for a presentation to be well-structured so it can have the most impact on your audience. An unstructured presentation can be difficult to follow and even frustrating to listen to. The heart of your speech are your main points supported by evidence and your transitions should assist the movement between points and clarify how everything is linked.

Research suggests that the audience remember the first and last things you say so your introduction and conclusion are vital for reinforcing your points. Essentially, ensure you spend the time structuring your presentation and addressing all of the sections.

• Mammary Glands
• Fallopian Tubes
• Supporting Ligaments
• Reproductive System
• Gametogenesis
• Placental Development
• Maternal Adaptations
• Menstrual Cycle
• Antenatal Care
• Small for Gestational Age
• Large for Gestational Age
• RBC Isoimmunisation
• Prematurity
• Prolonged Pregnancy
• Multiple Pregnancy
• Miscarriage
• Recurrent Miscarriage
• Ectopic Pregnancy
• Hyperemesis Gravidarum
• Gestational Trophoblastic Disease
• Breech Presentation
• Abnormal lie, Malpresentation and Malposition
• Oligohydramnios
• Polyhydramnios
• Placenta Praevia
• Placental Abruption
• Pre-Eclampsia
• Gestational Diabetes
• Headaches in Pregnancy
• Haematological
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• Thyroid Disease in Pregnancy
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• Induction of Labour
• Operative Vaginal Delivery
• Prelabour Rupture of Membranes
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Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

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This chapter should be cited as follows: Okemo J, Gulavi E, et al , Glob. libr. women's med ., ISSN: 1756-2228; DOI 10.3843/GLOWM.414593

The Continuous Textbook of Women’s Medicine Series – Obstetrics Module

Common obstetric conditions

Volume Editor: Professor Sikolia Wanyonyi , Aga Khan University Hospital, Nairobi, Kenya

Abnormal Lie/Presentation

First published: February 2021

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INTRODUCTION

The mechanism of labor and delivery, as well as the safety and efficacy, is determined by the specifics of the fetal and maternal pelvic relationship at the onset of labor. Normal labor occurs when regular and painful contractions cause progressive cervical dilatation and effacement, accompanied by descent and expulsion of the fetus. Abnormal labor involves any pattern deviating from that observed in the majority of women who have a spontaneous vaginal delivery and includes:

• Protraction disorders (slower than normal progress);
• Arrest disorders (complete cessation of progress).

Among the causes of abnormal labor is the disproportion between the presenting part of the fetus and the maternal pelvis, which rather than being a true disparity between fetal size and maternal pelvic dimensions, is usually due to a malposition or malpresentation of the fetus.

This chapter reviews how to define, diagnose, and manage the clinical impact of abnormalities of fetal lie and malpresentation with the most commonly occurring being the breech-presenting fetus.

DEFINITIONS

At the onset of labor, the position of the fetus in relation to the birth canal is critical to the route of delivery and, thus, should be determined early. Important relationships include fetal lie, presentation, attitude, and position .

Fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99% of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent when the fetal and maternal axes may cross at a 90 ° angle, and predisposing factors include multiparity, placenta previa, hydramnios, and uterine anomalies. Occasionally, the fetal and maternal axes may cross at a 45 ° angle, forming an oblique lie . 

Fetal presentation

The presenting part is the portion of the fetal body that is either foremost within the birth canal or in closest proximity to it. Thus, in longitudinal lie, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations , respectively. The shoulder is the presenting part when the fetus lies with the long axis transversely.

Commonly the baby lies longitudinally with cephalic presentation. However, in some instances, a fetus may be in breech where the fetal buttocks are the presenting part. Breech fetuses are also referred to as malpresentations. Fetuses that are in a transverse lie may present the fetal back (or shoulders, as in the acromial presentation), small parts (arms and legs), or the umbilical cord (as in a funic presentation) to the pelvic inlet. When the fetal long axis is at an angle to the bony inlet, and no palpable fetal part generally is presenting, the fetus is likely in oblique lie. This lie usually is transitory and occurs during fetal conversion between other lies during labor.

The point of direction is the most dependent portion of the presenting part. In cephalic presentation in a well-flexed fetus, the occiput is the point of direction.

The fetal position refers to the location of the point of direction with reference to the four quadrants of the maternal outlet as viewed by the examiner. Thus, position may be right or left as well as anterior or posterior.

Unstable lie

Refers to the frequent changing of fetal lie and presentation in late pregnancy (usually refers to pregnancies >37 weeks).

Fetal position

Fetal position refers to the relationship of an arbitrarily chosen portion of the fetal presenting part to the right or left side of the birth canal. With each presentation there may be two positions – right or left. The fetal occiput, chin (mentum) and sacrum are the determining points in vertex, face, and breech presentations. Thus:

• left and right occipital presentations
• left and right mental presentations
• left and right sacral presentations.

Fetal attitude

The fetus instinctively forms an ovoid mass that corresponds to the shape of the uterine cavity towards the third trimester, a characteristic posture described as attitude or habitus. The fetus becomes folded upon itself to create a convex back, the head is flexed, and the chin is almost in contact with the chest. The thighs are flexed over the abdomen and the legs are bent at the knees. The arms are usually parallel to the sides or lie across the chest while the umbilical cord fills the space between the extremities. This posture is as a result of fetal growth and accommodation to the uterine cavity. It is possible that the fetal head can become progressively extended from the vertex to face presentation resulting in a change of fetal attitude from convex (flexed) to concave (extended) contour of the vertebral column.

The categories of frank, complete, and incomplete breech presentations differ in their varying relations between the lower extremities and buttocks (Figure 1). With a frank breech, lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head. With a complete breech, both hips are flexed, and one or both knees are also flexed. With an incomplete breech, one or both hips are extended. As a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal. A footling breech is an incomplete breech with one or both feet below the breech.

Types of breech presentation. Reproduced from WHO 2006, 1 with permission.

The relative incidence of differing fetal and pelvic relations varies with diagnostic and clinical approaches to care.

About 1 in 25 fetuses are breech at the onset of labor and about 1 in 100 are transverse or oblique, also referred to as non-axial. 2

With increasing gestational age, the prevalence of breech presentation decreases. In early pregnancy the fetus is highly mobile within a relatively large volume of amniotic fluid, therefore it is a common finding. The incidence of breech presentation is 20–25% of fetuses at <28 weeks, but only 7–16% at 32 weeks, and only 3–4% at term. 2 , 3

Face and brow presentation are uncommon. Their prevalence compared with other types of malpresentations are shown below. 4

• Occiput posterior – 1/19 deliveries;
• Breech – 1/33 deliveries;
• Face – 1/600–1/800 deliveries;
• Brow – 1/500–1/4000 deliveries;
• Transverse lie – 1/833 deliveries;
• Compound – 1/1500 deliveries.

Transverse lie is often unstable and fetuses in this lie early in pregnancy later convert to a cephalic or breech presentation.

The fetus has a relatively larger head than body during most of the late second and early third trimester, it therefore tends to spend much of its time in breech presentation or in a non-axial lie as it rotates back and forth between cephalic and breech presentations. The relatively large volume of amniotic fluid present facilitates this dynamic presentation.

Abnormal fetal lie is frequently seen in multifetal gestation, especially with the second twin. In women of grand parity, in whom relaxation of the abdominal and uterine musculature tends to occur, a transverse lie may be encountered. Prematurity and macrosomia are also predisposing factors. Distortion of the uterine cavity shape, such as that seen with leiomyomas, prior uterine surgery, or developmental anomalies (Mullerian fusion defects), predisposes to both abnormalities in fetal lie and malpresentations. The location of the placenta also plays a contributing role with fundal and cornual implantation being seen more frequently in breech presentation. Placenta previa is a well-described affiliate for both transverse lie and breech presentation.

Fetuses with congenital anomalies also present with abnormalities in either presentation or lie. It is possibly as a cause (i.e. fitting the uterine cavity optimally) or effect (the fetus with a neuromuscular condition that prevents the normal turning mechanism). The finding of an abnormal lie or malpresentation requires a thorough search for fetal abnormalities. Such abnormalities could include chromosomal (autosomal trisomy) and structural abnormalities (hydrocephalus), as well as syndromes of multiple effects (fetal alcohol syndrome).

In most cases, breech presentation appears to be as a chance occurrence; however, up to 15% may be owing to fetal, maternal, or placental abnormalities. It is commonly thought that a fetus with normal anatomy, activity, amniotic fluid volume, and placental location adopts the cephalic presentation near term because this position is the best fit for the intrauterine space, but if any of these variables is abnormal, then breech presentation is more likely.

Factors associated with breech presentation are shown in Table 1.

Risk factors for breech presentation.

Spontaneous version may occur at any time before delivery, even after 40 weeks of gestation. A prospective longitudinal study using serial ultrasound examinations reported the likelihood of spontaneous version to cephalic presentation after 36 weeks was 25%. 5

In population-based registries, the frequency of breech presentation in a second pregnancy was approximately 2% if the first pregnancy was not a breech presentation and approximately 9% if the first pregnancy was a breech presentation. After two consecutive pregnancies with breech presentation at delivery, the risk of another breech presentation was approximately 25% and this rose to 40% after three consecutive breech deliveries. 6 , 7

In addition, parents who themselves were delivered at term from breech presentation were twice as likely to have their offspring in breech presentation as parents who were delivered in cephalic presentation. This suggests a possible heritable component to fetal presentation. 8

Leopold’s maneuvers

The Leopold’s maneuvers: palpation of fetus in left occiput anterior position. Reproduced from World Health Organization, 2006, 1   with permission.

Abdominal examination can be conducted systematically employing the four maneuvers described by Leopold in 1894. 9 , 10 In obese patients, in polyhydramnios patients or those with anterior placenta, these maneuvers are difficult to perform and interpret.

The first maneuver is to assess the uterine fundus. This allows the identification of fetal lie and determination of which fetal pole, cephalic or podalic – occupies the fundus. In breech presentation, there is a sensation of a large, nodular mass, whereas the head feels hard and round and is more mobile.

The second maneuver is accomplished as the palms are placed on either side of the maternal abdomen, and gentle but deep pressure is exerted. On one side, a hard, resistant structure is felt – the back. On the other, numerous small, irregular, mobile parts are felt – the fetal extremities. By noting whether the back is directed anteriorly, transversely, or posteriorly, fetal orientation can be determined.

The third maneuver aids confirmation of fetal presentation. The thumb and fingers of one hand grasp the lower portion of the maternal abdomen just above the symphysis pubis. If the presenting part is not engaged, a movable mass will be felt, usually the head. The differentiation between head and breech is made as in the first maneuver.

The fourth maneuver helps determine the degree of descent. The examiner faces the mother’s feet, and the fingertips of both hands are positioned on either side of the presenting part. They exert inward pressure and then slide caudad along the axis of the pelvic inlet. In many instances, when the head has descended into the pelvis, the anterior shoulder or the space created by the neck may be differentiated readily from the hard head.

According to Lyndon-Rochelle et al ., 11 experienced clinicians have accurately identified fetal malpresentation using Leopold maneuvers with a high sensitivity 88%, specificity 94%, positive-predictive value 74%, and negative-predictive value 97%.

Vaginal examination

Prelabor diagnosis of fetal presentation is difficult as the presenting part cannot be palpated through a closed cervix. Once labor begins and the cervix dilates, and palpation through vaginal examination is possible. Vertex presentations and their positions are recognized by palpation of the various fetal sutures and fontanels, while face and breech presentations are identified by palpation of facial features or the fetal sacrum and perineum, respectively.

Sonography and radiology

Sonography is the gold standard for identifying fetal presentation. This can be done during antenatal period or intrapartum. In obese women or in women with muscular abdominal walls this is especially important. Compared with digital examinations, sonography for fetal head position determination during second stage labor is more accurate. 12 , 13

COMPLICATIONS

Adverse outcomes in malpresented fetuses are multifactorial. They could be due to either underlying conditions associated with breech presentation (e.g., congenital anomalies, intrauterine growth restriction, preterm birth) or trauma during delivery.

Neonates who were breech in utero are more at risk for mild deformations (e.g., frontal bossing, prominent occiput, upward slant and low-set ears), torticollis, and developmental dysplasia of the hip.

Other obstetric complications include prolapse of the umbilical cord, intrauterine infection, maldevelopment as a result of oligohydramnios, asphyxia, and birth trauma and all are concerns.

Birth trauma especially to the head and cervical spine, is a significant risk to both term and preterm infants who present breech. In cephalic presenting fetuses, the labor process prepares the head for delivery by causing molding which helps the fetus to adapt to the birth canal. Conversely, the after-coming head of the breech fetus must descend and deliver rapidly and without significant change in shape. Therefore, small alterations in the dimensions or shape of the maternal bony pelvis or the attitude of the fetal head may have grave consequences. This process poses greater risk to the preterm infant because of the relative size of the fetal head and body. Trauma to the head is not eliminated by cesarean section; both intracranial and cervical spine trauma may result from entrapment in either the uterine or abdominal incisions.

In resource-limited countries where ultrasound imaging, urgent cesarean delivery, and neonatal intensive care are not readily available, the maternal and perinatal mortality/morbidity associated with transverse lie in labor can be high. Uterine rupture from prolonged labor in a transverse lie is a major reason for maternal/perinatal mortality and morbidity.

EXTERNAL CEPHALIC VERSION

External cephalic version (ECV) is the manual rotation of the fetus from a non-cephalic to a cephalic presentation by manipulation through the maternal abdomen (Figure 3).

External version of breech presentation . Reproduced from WHO 2003 , 14  with  permission .

This procedure is usually performed as an elective procedure in women who are not in labor at or near term to improve their chances of having a vaginal cephalic birth. ECV reduces the risk of non-cephalic presentation at birth by approximately 60% (relative risk [RR] 0.42, 95% CI 0.29–0.61) and reduces the risk of cesarean delivery by approximately 40% (RR 0.57, 95% CI 0.40–0.82). 7

In a 2008 systematic review of 84 studies including almost 13,000 version attempts at term, the pooled success rate was 58%. 15  

A subsequent large series of 2614 ECV attempts over 18 years reported a success rate of 49% and provided more details): 16

• The success rate was 40% in nulliparous women and 64% in parous women.
• After successful ECV, 97% of fetuses remained cephalic at birth, 86% of which were delivered vaginally.
• Spontaneous version to a cephalic presentation occurred after 4.3% of failed attempts, and 2.2% of successfully vertexed cases reverted to breech.

Factors associated with lower ECV success rates include nulliparity, anterior placenta, lateral or cornual placenta, decreased amniotic fluid volume, low birth weight, obesity, posteriorly located fetal spine, frank breech presentation, ruptured membranes.

The following factors should be considered while managing malpresentations: type of malpresentation, gestational age at diagnosis, availability of skilled personnel, institutional resources and protocols and patient factors and preferences.

Breech presentation

According to a term breech trial, 17 planned cesarean delivery carries a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to vaginal breech delivery. When planning a breech vaginal birth, appropriate patient selection and skilled personnel in breech delivery are key in achieving good neonatal outcomes. In appropriately selected patients and skilled personnel in vaginal breech deliveries, perinatal mortality is between 0.8 and 1.7/1000 for planned vaginal breech birth and between 0 and 0.8/1000 for planned cesarean section. 18 , 19 The choice of the route of delivery should therefore be made considering the availability of skilled personnel in conducting breech vaginal delivery; providing competent newborn care; conducting rapid cesarean delivery should need arise and performing ECV if desired; availability of resources for continuous intrapartum fetal heart rate and labor monitoring; patient clinical features, preferences and values; and institutional policies, protocols and resources.

Four approaches to the management of breech presentation are shown in Figure 4: 8

Management of breech presentation. ECV, external cephalic version.

The options available are:

• Attempting external cephalic version (ECV) before labor with a trial of labor if successful and conducting cesarean delivery if unsuccessful.
• Footling or kneeling breech presentation;
• Fetal macrosomia;
• Fetal growth restriction;
• Hyperextended fetal neck in labor;
• Previous cesarean delivery;
• Unavailability of skilled personnel in breech delivery;
• Other contraindications to vaginal delivery like placenta previa, cord prolapse;
• Fetal anomaly that may interfere with vaginal delivery like hydrocephalus.
• Planned cesarean delivery without an attempt at ECV.
• Planned trial of vaginal breech delivery in patients with favorable clinical characteristics for vaginal delivery without an attempt at ECV.

All the four approaches should be discussed in detail with the patient, and in light of all the considerations highlighted above, a safe plan of care agreed upon by both the patient and the clinician in good time.

Transverse and oblique lie

If a diagnosis of transverse/oblique fetal lie is made before onset of labor and there are no contraindications to vaginal birth or ECV, ECV can be attempted at 37 weeks' gestation. If the malpresentation recurs, further attempts at ECV can be made at 38–39 weeks with induction of labor if successful.

ECV can also be attempted in early labor with intact fetal membranes and no contraindications to vaginal birth.

If ECV is declined or is unsuccessful, then planned cesarean section should be arranged after 39 weeks' gestation.

MANAGEMENT OF LABOR AND DELIVERY

Skills to conduct vaginal breech delivery are very important as there are women who may opt for planned vaginal breech birth and even among those who choose planned cesarean delivery, about 10% may go into labor and end up with a vaginal breech delivery. 17 Some implications of cesarean delivery such as need for repeat cesarean deliveries, placental attachment disorders and uterine rupture make vaginal birth more desirable to some individuals. In addition, vaginal birth has advantages such as affordability, quicker recovery, shorter hospital stay, less complications and is more favorable for resource poor settings.

In appropriately selected women, planned vaginal breech birth is not associated with any significant long-term neurological morbidity. Regardless of planned mode of birth, cerebral palsy occurs in approximately 1.5/1,000 breech births, and abnormal neurological development occurs in approximately 3/100. 18 Careful patient selection is very important for good outcomes and it is generally agreed that women who choose to undergo a trial of labor and vaginal breech delivery should be at low risk of complications from vaginal breech delivery. Some contraindications to vaginal breech delivery have been highlighted above.

Women with breech presentation near term, pre- or early-labor ultrasound should be performed to assess type of breech presentation, flexion of the fetal head and fetal growth. If a woman presents in labor and ultrasound is unavailable and has not recently been performed, cesarean section is recommended. Vaginal breech deliveries should only take place in a facility with ability and resources readily available for emergency cesarean delivery should the need arise.

Induction of labor may be considered in carefully selected low-risk women. Augmentation of labor is controversial as poor progress of labor may be a sign of cephalo-pelvic disproportion, however, it may be considered in the event of weak contractions. A cesarean delivery should be performed if there is poor progress of labor despite adequate contractions. Labor analgesia including epidural can be used as needed.

Vaginal breech delivery should be conducted in a facility that is able to carry out continuous electronic fetal heart rate monitoring sufficient personnel to monitor the progress of labor. From the term breech trial, 17 the commonest indications for cesarean section are poor progress of labor (50%) and fetal distress (29%). There is an increased risk of cord compression which causes variable decelerations. Since the fetal head is at the fundus where contractions begin, the incidence of early decelerations arising from head compression is also higher. Due to the irregular contour of the presenting part which presents a high risk of cord prolapse, immediate vaginal examination should be undertaken if membranes rupture to rule out cord prolapse. The frequency of cord prolapse is 1% with frank breech and more than 10% in footling breech. 8

Fetal blood sampling from the buttocks is not recommended. A passive second stage of up to 90 minutes before active pushing is acceptable to allow the breech to descend well into the pelvis. Once active pushing commences, delivery should be accomplished or imminent within 60 minutes. 18

During planned vaginal breech birth, a skilled clinician experienced in vaginal breech birth should supervise the first stage of labor and be present for the active second stage of labor and delivery. Staff required for rapid cesarean section and skilled neonatal resuscitation should be in-hospital during the active second stage of labor.

The optimum maternal position in second stage has not been extensively studied. Episiotomy should be undertaken as needed and only after the fetal anus is visible at the vulva. Breech extraction of the fetus should be avoided. The baby should be allowed to deliver spontaneously with maternal effort only and without any manipulations at least until the level of the umbilicus. A loop of the cord is then pulled to avoid cord compression. After this point, suprapubic pressure can be applied to facilitate flexion of the fetal head and descent.

Delay of arm delivery can be managed by sweeping them across the face and downwards towards in front of the chest or by holding the fetus at the hips or bony pelvis and performing a 180° rotation to deliver the first arm and shoulder and then in the opposite direction so that the other arm and shoulder can be delivered i.e.,  Lovset’s maneuver (Figure 5).

Lovset’s maneuver. Reproduced from WHO 2006 , 1  with  permission . 

The fetal head can deliver spontaneously or by the following maneuvers:

• Turning the body to the floor with application of suprapubic pressure to flex the head and neck.

Mauriceau-smellie-veit maneuver . Reproduced from WHO 2003, 14 with permission.

• By use of Piper’s forceps.
• Burns-Marshall maneuver  where the baby’s legs and trunk are allowed to hang until the nape of the neck is visible at the mother’s perineum so that its weight exerts gentle downwards and backwards traction to promote flexion of the head. The fetal trunk is then swept in a wide arc over the maternal abdomen by grasping both the feet and maintaining gentle traction; the aftercoming head is slowly born in this process.

If the above methods fail to deliver the fetal head, symphysiotomy and zavanelli maneuver with cesarean section can be attempted. Duhrssen incisions where 1–3 full length incisions are made on an incompletely dilated cervix at the 6, 2 and 10 o’clock positions can be done especially in preterm.

Face presentation

The diagnosis of face presentation is made during vaginal examination where the presenting portion of the fetus is the fetal face between the orbital ridges and the chin. At diagnosis, 60% of all face presentations are mentum anterior, 26% are mentum posterior and 15% are mentum transverse. Since the submentobregmatic (face presentation) and suboccipitobregmatic (vertex presentation) have the same diameter of 9.5 cm, most face presentations can have a successful vaginal birth and not necessarily require cesarean section delivery. 6 The position of a fetus in face presentation helps in guiding the management plan. Over 75% of mentum anterior presentations will have a successful vaginal delivery, whereas it is impossible to have a vaginal birth in mentum posterior position unless it converts spontaneously to mentum anterior position. In mentum posterior position the neck is maximally extended and cannot extend further to deliver beneath the symphysis pubis (Figure 7).

Face presentation. Reproduced from WHO 2003, 14 with permission.

As in breech management, face presentation also requires continuous fetal heart rate monitoring, since abnormalities of fetal heart rate are more common. 5 , 6 In one study , 20 only 14% of pregnancies had normal tracings, 29% developed variable decelerations and 24% had late decelerations. Internal fetal heart rate monitoring with an electrode is not recommended, as it may cause facial and ophthalmic injuries if incorrectly placed. Labor augmentation and cesarean sections are performed as per standard obstetric indications. Vacuum and midforceps delivery should be avoided, but an outlet forceps delivery can be attempted. Attempts to manually convert the face to vertex or to rotate a posterior position to a more favorable anterior mentum position are rarely successful and are associated with high fetal morbidity and mortality, and maternal morbidity, including cord prolapse, uterine rupture, and fetal cervical spine injury with neurological impairment.

Brow presentation

The diagnosis of brow presentation is made during vaginal examination in second stage of labor where the presenting portion of the fetal head is between the orbital ridge and the anterior fontanel.

Brow presentation may be encountered early in labor, but is usually a transitional state and converts to a vertex presentation after the fetal neck flexes. Occasionally, further extension may occur resulting in a face presentation. The majority of brow presentations diagnosed early in labor convert to a more favorable presentation and deliver vaginally. Once brow presentation is confirmed, continuous fetal heart rate monitoring is necessary and labor progress should be monitored closely in order to pick any signs of abnormal labor. Since the brow diameter is large (13.5 cm), persistent brow presentation usually results in prolonged or arrested labor requiring a cesarean delivery. Labor augmentation and instrumental deliveries are therefore not recommended.

CESAREAN DELIVERY

This is an option for women with breech presentation at term to choose cesarean section as their preferred mode of delivery, for those with unsuccessful ECV who do not want to attempt vaginal breech delivery, have contraindications for vaginal breech delivery or in the event that there is no available skilled personnel to safely conduct a vaginal breech delivery. Women should be given enough and accurate information about pros and cons for both planned cesarean section and planned vaginal delivery to help them make an informed decision.

Since the publication of the term breech trial, 17 , 19 there has been a dramatic global shift from selective to planned cesarean delivery for women with breech presentation at term. This study revealed that planned cesarean section carried a reduced perinatal mortality and early neonatal morbidity for babies with breech presentation at term compared to planned vaginal birth (RR 0.33, 95% CI 0.19–0.56). The cesarean delivery rate for breech presentation is now about 70% in European countries, 95% in the United States and within 2 months of the study’s publication, there was a 50–80% increase in rates of cesarean section for breech presentation in The Netherlands.

A planned cesarean delivery should be scheduled at term between 39–41 weeks' gestation to allow maximum time for spontaneous cephalic version and minimize the risk of neonatal respiratory problems. 8 Physical exam and ultrasound should be performed immediately prior to the surgery to confirm the fetal presentation. A detailed consent should be obtained prior to surgery and should include both short- and long-term complications of cesarean section and the alternatives of care that are available. The abdominal and uterine incisions should be sufficiently large to facilitate easy delivery. Thereafter, extraction of the fetus is similar to what is detailed above for vaginal delivery.

Cesarean section for face presentation is indicated for persistent mentum posterior position, mentum transverse and some mentum anterior positions where there is standard indication for cesarean section.

Persistent brow presentation usually necessitates cesarean delivery due to the large presenting diameter that causes arrest or protracted labor.

Transverse/oblique lie

Cesarean section is indicated for patients who present in active labor, in those who decline ECV, following an unsuccessful ECV or in those with contraindications to vaginal birth.

For dorsosuperior (back up) transverse lie, a low transverse incision is made on the uterus and an attempt to grasp the fetal feet with footling breech extraction is made. If this does not succeed, a vertical incision is made to convert the hysterotomy into an inverted T incision.

Dorsoinferior (back down) transverse lie is more difficult to deliver since the fetal feet are hard to grasp. An attempt at intraabdominal version to cephalic or breech presentation can be done if membranes are intact before the uterine incision is made. Another option is to make a vertical uterine incision; however, the disadvantage of this is the risk of uterine rupture in subsequent pregnancies.

PERINATAL OUTCOME

Availability of skilled neonatal care at delivery is important for good perinatal outcomes to facilitate resuscitation if needed for all fetal malpresentations. 8 All newborns born from fetal malpresentations require a thorough examination to check for possible injuries resulting from birth or as the cause of the malpresentation.

Neonates who were in face presentation often have facial edema and bruising/ecchymosis from vaginal examinations that usually resolve within 24–48 hours of life and low Apgar scores. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress and difficulties in resuscitative efforts.

PRACTICE RECOMMENDATIONS

• Diagnosis of unstable lie is made when a varying fetal lie is found on repeated clinical examination in the last month of pregnancy.
• Consider external version to correct lie if not longitudinal.
• Consider ultrasound to exclude mechanical cause.
• Inform woman of need for prompt admission to hospital if membranes rupture or when labor starts.
• If spontaneous rupture of membranes occurs, perform vaginal examination to exclude the presence of a cord or malpresentation.
• If the lie is not longitudinal in labor and cannot be corrected perform cesarean section.

CONFLICTS OF INTEREST

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Malpresentation, Abnormal lie and Position Including Unstable lie

Compiled by Victortayo

last updated, Nov 2022

Introduction

• Types of malpresentation

Breech presentation

Face presentation, brow presentation.

• Cord presentation

Compound presentation

Abnormal lie, unstable lie, malpositioning, definitions.

Presentation : is that part which is in or over the pelvic brim and in relation to the cervix. It is the part of the fetus occupying the lower uterine segment. The presenting part is the leading part of the leading portion of presentation felt at vaginal examination. Normal presentation is cephalic while normal presenting part is the vertex. Abnormal presentation occurs when the fetus presents in any other manner other than vertex such as breech, face, brow and shoulder presentations.

Lie : is the relationship between the long axis of the fetus and the long axis of the mother. Fetal lie can be longitudinal, transverse or oblique.

Position : is the relationship of a denominator in the presenting part to the maternal pelvis

Denominator : is the part of the presenting part, which denote the position. The denominators for cephalic, breech and shoulder presentations are vertex, sacrum and acromion respectively.

Attitude : refers to the position of the head with regard to the fetal spine (the degree of flexion and extension of the fetal head). The normal attitude is one of flexion.

Station : is a measure of descent of the bony presenting part of the fetus through the birth canal. The current standard of classification (-5 to +5) is based on a measure in centimeters of the distance of the leading bony edge from the ischial spine.

Engagement : refers to passage of the widest diameter of the presentation to a level below the plane of the pelvic inlet.

Types of malpresentations

Most common type of malpresentation.

Causes/risk factors

• In most cases, no apparent cause is discernable.
• Incidence is increased among multiparous women when compared to nulliparous women.
• Presence of pelvic tumors preventing the engagement of the presenting part increases the chances of breech presentation.
• Abnormalities of uterine shape
• Abnormalities of placentation
• Cephalopelvic disproportion
• Prematurity
• Anencephaly
• Hydrocephalus
• Neck tumors
• Multiple pregnancies
• Polyhydraminos/oligohydramnios

Based on findings of a hard ballotable head in the upper segment of the uterus with the soft, round bottom in the lower uterine pole.

Diagnosis is confirmed using an ultrasound scan which may also show other abnormalities such as placenta previa, abnormal liquor volume, pelvic tumors, etc.

Elective cesarean section

External cephalic version- carried out by trained providers in a setting that has ready access to a cesarean section.

Planned vaginal delivery might be possible in carefully selected women in whom unfavorable factors have been excluded and where appropriately trained personnel are on hand to conduct the delivery. It should only be offered in a facility with ready recourse to a cesarean section.

Occurs when the fetal head is hyperextended

Incidence is 1 in 500 labors

In early labor, minor deflexion occurs which may progress to hyperextension

Types of face presentation:

• Mentoanterior face 77% (commoner)
• Mentoposterior face

Presenting diameter is submento-bregmatic- 9.5cm

No cause could be found in >70%

• Multiple pregnancy
• Polyhydramnios
• Pelvic tumors
• Placenta previa
• Tumor of the fetal neck
• Commoner in multiparas

In early labor, the presenting part is high

Feel for the mouth, jaws, nose, malar and orbital ridges.

Mouth and maxillae form the corners of a triangle.

For mentoanterior face-

• Spontaneous delivery/(augmentation)
• Lift-out forceps
• Vaginal delivery - 80%

Mentoposterior face-

• Augmentation
• Cesarean section commonly

Complications-

• Facial edema
• Soft tissue trauma

Incidence- 1 in 1050

Many brow presentation in labor are transient

Midway in position between face and vertex presentation

Proceeding to full deflexion = face presentation

Or undergo spontaneous flexion= vertex presentation

Mentovertical diameter is 13.5cm hence it cannot engage in normal pelvis

Similar to face presentation

Vaginal examination-

• High presenting part
• Bregma occupies the centre of dilating cervix, -frontal suture, anterior fontanelle, and orbital region can be identified
• Nose, mouth and chin cannot be felt as in face presentation

With persistent brow (average sized fetus and normal pelvis), engagement is impossible because of the wide presenting diameter

Presenting part is high

C/S is best option

Cord presentation : the umbilical cord is below the presenting part (head in the picture below but commonly a malpresentation) with the membranes intact.

Cord prolapse : the membranes have ruptured and the cord is beow the presenting part and has prolapsed into the vagina.

overall incidence of cord presentation is 0.1%-0.6%. It is much higher in breech presentation.

• Cord prolapse

Risk factors

Factors preventing the proper fitting of the fetal presenting part predispose to cord prolapse. These include

• Low birth weight
• Second twin
• Low lying placenta

Other factors:

• Multiparity
• Procedures such as external cephalic version, internal podalic version, artificial rupture of membranes
• Use of large balloon catether for induction of labor.

Management of cord prolapse

Diagnosis is essentially clinical.

Electronic fetal monitoring can also be important for diagnosis when it is available. Abnormal FHR pattern following ROM may be the first indication of cord prolapse.

It is diagnosed by seeing or palpating the prolapsed cord on pelvic exam.

When diagnosed, summon a senior colleague and prepare operating theater for emergency delivery.

Management of cord presentation is usually by emergency C/S

Factors to consider-

• Is the fetus alive or dead?
• Lie/presentation
• Cervical dilatation

Live fetus –

• Attempt to prevent further cord compression by
• Elevating mother buttocks (knee chest position) or left lateral position
• Manually pushing the fetal head (presenting part) out of the pelvis
• Avoid handling the cord as this causes cord spasm.
• Fill the bladder with 500-700mls of normal saline
• Cephalic presenting fetus with cord prolapse
• Cervix <8cm = c/s
• Cervix ≥ 8cm -assisted vaginal delivery
• Dead fetus –
• Expectant management (vaginal delivery)
• Destructive operation

Perinatal mortality associated with cord prolapse is high. These usually result from asphyxia caused by delay in effecting delivery.

One or more limbs precede or lie alongside with the head in vertex presentation.

Usually the arms or where one or both arms or hands present with breech

Twins pregnancy

SROM with high presenting part

Diagnosis is easy. The limb and presenting part is felt occupying the pelvis

Management-

Expectant management (the arm usually rise into the uterus with contraction)

• Transverse lie (shoulder presentation)
• Oblique lie

Predisposing factors / associated factors

• High parity
• Placenta praevia
• Transverse lie- fetal poles are in flanks
• Oblique lie- fetal poles are in iliac fossa and hypochondrial region

Management:

Persistent transverse lie or transverse lie in labor = C/S

There is a place for External cephalic version

Frequent changing of fetal lie and presentation in late pregnancy (>37weeks)

Stabilization, induction at term

• External cephalic version (ECV)
• Stabilizing the fetal head (maintain cephalic presentation)
• Induction of labor (perform amniotomy achieving uterine contraction, continue oxytocin infusion)

Occipitoposterior position (face to pubis)

• Pelvis shape
• Deflexion of fetal head
• The abdomen is flat
• Fetal limbs are easily palpable
• On vaginal examination, the anterior fontanelle can be felt behind the symphysis
• Direction of the fetal ear
• Good uterine contraction/augmentation of labor= spontaneous version
• Vacuum extraction

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Unstable angina.

Amandeep Goyal ; Roman Zeltser .

Affiliations

Last Update: September 18, 2022 .

• Continuing Education Activity

Unstable angina is chest discomfort or pain caused by an insufficient flow of blood and oxygen to the heart. It is part of the acute coronary syndromes and may lead up to a heart attack. This activity describes the evaluation and management of unstable angina and reviews the role of the interprofessional team in improving care for patients with this condition.

• Outline the role of coronary artery disease in the etiology of unstable angina.
• Describe the pathophysiology of unstable angina.
• Identify the ECG changes in the evaluation of unstable angina.
• Review the importance of improving care coordination among the interprofessional team to improve outcomes for patients affected by unstable angina.
• Introduction

Unstable angina falls along a spectrum under the umbrella term acute coronary syndrome. This public health issue that daily affects a large portion of the population remains the leading cause of death worldwide. Distinguishing between this and other causes of chest pain that include stable angina is important regarding the treatment and disposition of the patient. Providers should be aware of the signs and symptoms of acute coronary syndrome as patients rely on health care professionals to make the distinction from other causes of chest pain. Often patients will present to the emergency room. However, acute coronary syndrome can be seen in the outpatient setting as well. Over the years, a significant amount of research has gone into determining the appropriate and most effective treatment modalities, as well as the diagnostic tools available, in evaluating unstable angina and the other variants of acute coronary syndrome.  [1] [2] [3]

Coronary atherosclerotic disease is the underlying cause of unstable angina in nearly all patients with acute myocardial ischemia. The most common cause of unstable angina is due to coronary artery narrowing due to a thrombus that develops on a disrupted atherosclerotic plaque and is nonocclusive.

A less common cause is vasospasm of a coronary artery (variant Prinzmetal angina). Endothelial or vascular smooth dysfunction causes this vasospasm. [4]

• Epidemiology

Coronary artery disease affects a large portion of the population. It is estimated that coronary artery disease causes more than a third of deaths in people over the age of 35. It is the leading cause of death in this particular age group. Roughly 18 million within the United States alone are estimated to be affected by this disease. The incidence is higher in men, but as individuals surpass the age of 75, the incidence of males and females becomes much closer. Other risk factors include obesity, diabetes, hypertension, high cholesterol, smoking history, cocaine or amphetamine abuse, family history, chronic kidney disease, HIV, autoimmune disorders, and anemia. [5]

The mean age of presentation is 62, and women tend to be older than men. African Americans tend to present at a younger age.

• Pathophysiology

Unstable angina deals with blood flow obstacles causing a lack of perfusion to the myocardium. Initial perfusion starts directly from the heart into the aorta and subsequently into the coronary arteries, which supply their respective portions of the heart. The left coronary artery will divide into the circumflex and the left anterior descending artery.  Subsequently, this will divide into much smaller branches. The right coronary will divide into smaller branches as well. Unstable angina results when the blood flow is impeded to the myocardium. Most commonly, this block can be from intraluminal plaque formation, intraluminal thrombosis, vasospasm, and elevated blood pressure.  Often a combination of these is the provoking factor.

Factors that increase myocardial oxygen demand:

• Arrhythmias
• Hypertension
• Cocaine use
• Aortic stenosis
• Thyrotoxicosis
• Pheochromocytoma
• History and Physical

Patients will often present with chest pain and shortness of breath. The chest pain will often be described as pressure-like, although it is not necessarily limited to this description. Tightness, burning, and sharp types of pain can be described. Often patients will report discomfort as opposed to actual pain. The pain will often radiate to the jaw or arms, and both the left and right sides can be affected. Constitutional symptoms such as nausea, vomiting, diaphoresis, dizziness, and palpitations may also be present. Exertion may worsen pain, and rest can ease the pain.  Nitroglycerin and aspirin administration may also improve the pain.  One distinguishing factor of unstable angina is that the pain may not completely resolve with these reported relieving factors. Also, many patients will already have coronary artery disease. This may be either established coronary artery disease or symptoms they have been experiencing for some time. These patients may have familiarity with the symptoms and may report an increase in episodes of chest pain that takes longer to resolve and an increase in the severity of symptoms. These symptoms indicate unstable angina as the more likely diagnosis, as opposed to stable angina or other causes of chest pain. This is important to note as these differences may indicate impending myocardial infarction and ST-elevation myocardial infarction (STEMI) and should be evaluated expeditiously as the risk of morbidity and mortality are higher in this scenario versus stable angina.

The exam will likely be normal, although the patient may be clutching at their chest, sweating, have labored breathing, their heart sounds may be tachycardic, and rales may be heard due to pulmonary edema.

Findings suggestive of a high-risk situation include:

• Dyskinetic apex
• Elevated JVP
• Presence of S3 or S4
• New apical systolic murmur
• Presence of rales and crackles
• Hypotension

When a patient presents, he or she should be evaluated quickly.  The patient should have an ECG to evaluate for ischemic signs or possible STEMI. The ECG in unstable angina may show hyperacute T-wave, flattening of the T-waves, inverted T-waves, and ST depression. ST elevations indicate STEMI, and these patients should be treated with percutaneous coronary intervention or thrombolytics while they wait on the availability of a catheterization lab. Any number of arrhythmias may be present in acute coronary syndrome, including junctional rhythms, sinus tachycardia, ventricular tachycardia, ventricular fibrillation, left bundle branch block, and others. However, most commonly, the patient will be in sinus rhythm, especially in the scenario of unstable angina as opposed to infarcted tissue.

The patient should also have lab work that includes a complete blood count evaluating for anemia, platelet count, and basic metabolic profile evaluating for electrolyte abnormalities. A troponin test should be performed to determine if any of the myocardium has infarcted. A pro-brain natriuretic peptide (Pro-BNP) can also be checked, as an elevated level is associated with higher mortality. Coagulation studies may be appropriate if the patient will be anticoagulated or anticoagulation is anticipated. Often, a chest x-ray will show the heart size and the size of the mediastinum so the physician may screen for dissection and other explanations of chest pain.

It should be stated here that the history should be screened for other emergent causes of chest pain, shortness of breath, pulmonary embolism, aortic dissection, esophageal rupture, pneumonia, and pneumothorax. The patient should be kept on a cardiac monitor to evaluate for any rhythm changes. Further testing may include any number of cardiac stress tests (walking treadmill stress test, stress echocardiogram, myocardial perfusion imaging, cardiac CT/MRI, or the gold standard, cardiac catheterization). These are typically ordered and performed by inpatient providers and primary care providers, but with observation medicine growing, emergency medicine providers may order these.  [6] [7]

Acute coronary syndrome risk assessment:

• Prior MI, or known history of CAD
• Transient ECG or hemodynamic changes during chest pain
• Chest, neck, or left arm with documented angina
• ST depression or elevation of more than 1 mm
• Marked symmetrical T wave inversion
• Treatment / Management

The mainstay of treatment focuses on improving perfusion of the coronary arteries. This is done in several ways.

Patients are often treated with aspirin for its antiplatelet therapies, 162 to 325 mg orally or 300 mg rectally if the patient is unable to swallow. The aspirin should be administered within 30 minutes. Nitroglycerin comes in several forms (intravenous, sublingual, transdermal, orally) and improves perfusion by vasodilation of the coronaries allowing improved flow and improved blood pressure. This will decrease the amount of work the heart has to perform, which decreases the energy demand of the heart.

Clopidogrel is an option for patients not able to tolerate aspirin. Prasugrel is more effective than clopidogrel but is associated with a higher risk of bleeding. Recently ticagrelor has been approved in addition to aspirin to reduce the rate of thrombotic cardiac events.

Supplemental oxygen should be given as well via nasal cannula to maintain appropriate oxygen saturation. These 3 actions are the quickest and most important functions to be performed in evaluating and treating unstable angina. In patients with continued pain or longer recovery time, the patient's response should be evaluated because they are at much higher risk for myocardial infarction.

Other potential therapies include anticoagulation with either low or high molecular weight heparin. Beta-blockers also can decrease the energy demand by decreasing blood pressure and heart rate.  [1] [8] [9]  Ranolazine use was studied in patients with unstable angina. There was a significant reduction in the endpoint of recurrent ischemia in the ranolazine group. [10]

Many trials have validated the use of statins in patients with unstable angina.

Cardiac angiography is indicated in unstable angina if the patient has:

• Cardiogenic shock
• Depressed ejection fraction
• Angina refractory to pharmacological therapy
• Unstable arrhythmias

Early PCI in NSTEMI (within 6 hours) has been shown to have lower mortality than those who undergo delayed PCI.

• Differential Diagnosis
• Aortic dissection
• Pericarditis
• Pneumothorax
• Pulmonary embolism
• Peptic ulcer disease

The key complications of unstable angina include:

• Myocardial infarction (MI)

Evidence shows that patients with new-onset ST-segment elevation (more than 1 mm) have a 12-month rate of an MI or death of about 11%, compared to only 7% for patients who only have isolated inversion of the T wave.

Negative prognostic factors include:

• Low ejection fraction
• Ongoing congestive heart failure (CHF)
• New or worsening MR
• Hemodynamic instability
• Sustained VT
• Recurrent episodes of angina despite maximal therapy
• Consultations

Once a patient has been diagnosed with unstable angina, a cardiologist and a cardiac surgeon should be consulted. The cardiologist will need to stratify the risk and help make a decision in management.

• Deterrence and Patient Education

The goals of prevention are to enable the patient to resume all daily living activities, preserve myocardial function and prevent future cardiac events. Today, most cardiac centers have specialized teams like cardiac rehab that offer intensive and more effective counseling.

Smoking cessation is mandatory to prevent recurrent cardiac events. This applies to everyone in the household Lipid-lowering should try and obtain a target LDL-C level of 70 mg/dl or lower, an HDL level of at least 35 mg/dl, and a triglyceride level of less than 200 mg/dl.

The patient should exercise and eat a low-fat diet.

Control of Hypertension

The target blood pressure should be below 140/90 mm Hg. At the same time, the patient should decrease the intake of sodium and alcohol

Diabetes Mellitus Management

Blood sugar levels may be decreased with diet, exercise, or pharmacotherapy.

Weight Management and Nutritional Counseling

The patient should be encouraged to lose weight and achieve a body mass index (BMI) of 25 kg/m

Activity Management

Patients at risk for unstable angina should avoid intense physical activity, especially in cold weather.

• Pearls and Other Issues

Legally, unstable angina and other variants of acute coronary syndrome constitute a large portion of cases brought against providers. Aggressive evaluations of chest pain, in general, have led to over-testing, high admission rates, and often false positives resulting in inappropriate testing. Over the years, several rules have been developed to limit inappropriate admissions and testing. Several of these have variable sensitivity and specificity. With the number of legal cases that are brought on, physicians are often still somewhat aggressive in the management and treatment of chest pain involving potential acute coronary syndrome.

• Enhancing Healthcare Team Outcomes

Unstable angina is a very common disorder that is seen in the emergency room. There are many recommendations for the management of this serious cardiac disorder. Current recommendations are that this disorder should be managed by an interprofessional team that includes primary health care providers, nurse practitioners, physician assistants, pharmacists, cardiologists, and emergency room physicians, functioning together as an interprofessional team. In addition, a consult from a cardiac surgeon is highly recommended. Both the American College of Cardiology and the American Heart Foundation has issued guidelines on the management of unstable angina. [11]  [Level 5]

Once the patient has stabilized, prevention is key. The nurse practitioner, pharmacist, and primary care provider should urge the patient to quit smoking, eat a healthy diet, resume regular exercise, maintain a healthy body weight, and remain compliant with medications. Close follow-up is necessary to ensure that patients are meeting the goals of cardiac rehab. Further, lipid-lowering is vital to reduce the risk of recurrent unstable angina; the pharmacist should provide input and check dosing and potential drug-drug interactions. Finally, the nurse and pharmacist should emphasize the importance of blood pressure control and management of diabetes. Nursing will do most ongoing monitoring, evaluate treatment effectiveness, and alert the clinician to any potential issues. This type of interprofessional teamwork yields the best outcomes. [Level 5]

Today most hospitals have healthcare teams that specialize in the management of unstable angina. The members of this team need to be familiar with the latest guidelines and support patients with education on the reduction of risk factors and the benefits of compliance with medications.

Ample evidence exists that quality improvement programs have the lowest morbidity and best outcomes. [12]  [Level 2]

• Review Questions
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• Comment on this article.

Different types of angina in the coronary artery. Stable angina, unstable angina, variant angina. Contributed by Chelsea Rowe

Disclosure: Amandeep Goyal declares no relevant financial relationships with ineligible companies.

Disclosure: Roman Zeltser declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Goyal A, Zeltser R. Unstable Angina. [Updated 2022 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Unstable Angina

(acute coronary insufficiency; preinfarction angina; intermediate syndrome).

• Symptoms and Signs |
• Diagnosis |
• Treatment |
• Prognosis |
• Key Points |

Unstable angina results from acute obstruction of a coronary artery without myocardial infarction. Symptoms include chest discomfort with or without dyspnea, nausea, and diaphoresis. Diagnosis is by electrocardiography (ECG) and the presence or absence of biomarkers. Treatment is with antiplatelets, anticoagulants, nitrates, statins, and beta-blockers. Coronary angiography with percutaneous intervention or coronary artery bypass surgery is often necessary.

(See also Overview of Acute Coronary Syndromes .)

Unstable angina is a type of acute coronary syndrome that is defined as one or more of the following in patients whose cardiac biomarker levels do not meet criteria for acute myocardial infarction (MI):

Rest angina that is prolonged (usually > 20 minutes)

New-onset angina of at least class 3 severity in the Canadian Cardiovascular Society (CCS) classification (see table Canadian Cardiovascular Society Classification System for Angina Pectoris )

Increasing angina, ie, previously diagnosed angina that has become distinctly more frequent, more severe, longer in duration, or lower in threshold (eg, increased by ≥ 1 CCS class or to at least CCS class 3)

Unstable angina is clinically unstable and often a prelude to myocardial infarction or arrhythmias or, less commonly, to sudden death.

Symptoms and Signs of Unstable Angina

Patients have symptoms of angina pectoris (typically chest pain or discomfort) except that the pain or discomfort of unstable angina usually is more intense, lasts longer, is precipitated by less exertion, occurs spontaneously at rest, is progressive (crescendo) in nature, or involves any combination of these features.

Unstable angina is classified based on severity and clinical situation (see table Canadian Cardiovascular Classification System for Angina Pectoris ). Also considered are whether unstable angina occurs during treatment for chronic stable angina and whether transient changes in ST-T waves occur during angina. If angina has occurred within 48 hours and no contributory extracardiac condition is present, troponin levels may be measured to help estimate prognosis; troponin-negative results indicate a better prognosis than troponin-positive.

Diagnosis of Unstable Angina

Serial ECGs

Serial cardiac biomarkers

Immediate coronary angiography for patients with complications (eg, persistent chest pain, hypotension, unstable arrhythmias)

Delayed angiography (24 to 48 hours) for stable patients

(See figure Approach to Unstable Angina .)

Evaluation begins with initial and serial ECG and serial measurements of cardiac biomarkers to help distinguish between unstable angina and acute myocardial infarction (MI)—either non–ST-segment elevation MI (NSTEMI) or ST-segment elevation MI (STEMI). This distinction is the center of the decision pathway because fibrinolytics benefit patients with STEMI but k not those with NSTEMI and unstable angina. Also, urgent cardiac catheterization is indicated for patients with acute STEMI but not generally for those with NSTEMI or unstable angina.

ECG is the most important test and should be done as soon as possible (eg, within 10 minutes of presentation) ECG changes such as ST-segment depression, ST-segment elevation, or T-wave inversion may occur during unstable angina but are transient.

Cardiac biomarkers

Patients suspected of having unstable angina should have a highly sensitive assay of cardiac troponin (hs-cTn) done on presentation and 2 to 3 hours later. If a standard Tn assay is used, measurements are done at presentation and 6 hours later.

Creatine kinase MB fraction (CK-MB) is not elevated in unstable angina. Cardiac troponin, particularly when measured using high-sensitivity troponin tests, may be slightly increased but does not meet the criteria for myocardial infarction (above the 99th percentile of the upper reference limit or URL).

Coronary angiography

Patients with unstable angina whose symptoms have resolved typically undergo angiography within the first 24 to 48 hours of hospitalization to detect lesions that may require treatment. Coronary angiography most often combines diagnosis with percutaneous coronary intervention (PCI—ie, angioplasty, stent placement).

After initial evaluation and therapy, coronary angiography may be used in patients with evidence of ongoing ischemia (ECG findings or symptoms), hemodynamic instability, recurrent ventricular tachyarrhythmias , and other abnormalities that suggest recurrence of ischemic events.

Treatment of Unstable Angina

Pharmacologic therapy: Antiplatelet agents, antianginal drugs, anticoagulants, and in some cases other medications

Angiography to assess coronary artery anatomy

Reperfusion therapy: Percutaneous coronary intervention or coronary artery bypass surgery

Post-discharge rehabilitation and chronic medical management of coronary artery disease

Prehospital care

Triage to appropriate medical center

1 ). Early diagnostic data and response to treatment can help determine the need for and timing of revascularization .

Hospital admission

Risk-stratify patient and choose timing of reperfusion strategy

Pharmacologic therapy with antiplatelets, anticoagulants, and other medications based on reperfusion strategy

On arrival to the emergency department, the patient's diagnosis is confirmed. Pharmacologic therapy and timing of revascularization depend on the clinical picture. In clinically unstable patients (patients with ongoing symptoms, hypotension or sustained arrhythmias), urgent angiography with revascularization is indicated. In clinically stable patients, angiography with revascularization may be deferred for 24 to 48 hours (see figure Approach to Unstable Angina ).

Approach to Unstable Angina

Pharmacologic treatment of unstable angina.

All patients should be given antiplatelet agents , anticoagulants , and if chest pain is present, antianginals. The specific medications used depend on the reperfusion strategy and other factors; their selection and use is discussed in Medications for Acute Coronary Syndrome . Other medications, such as beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and statins, should be initiated during admission (see table Medications for Coronary Artery Disease ).

Patients with unstable angina should be given the following (unless contraindicated)

Antiplatelet agents

Anticoagulants : A heparin (unfractionated or low molecular weight heparin

Sometimes a glycoprotein IIb/IIIa inhibitor when PCI is done

Beta-blocker

Angiotensin-converting enzyme (ACE) inhibitor

Aspirin reduces short- and long-term mortality risk ( 2 prasugrel and ticagrelor are more rapid in onset and may be preferred.

Either a low molecular weight heparin (LMWH), unfractionated heparin heparin -induced thrombocytopenia.

Nitroglycerin is preferable to morphine , which should be used judiciously (eg, if a patient has a contraindication to nitroglycerin or is in pain despite maximal nitroglycerin therapy). is initially given sublingually, followed by continuous IV drip if needed. Morphine , given 2 to 4 mg IV, repeated every 15 minutes as needed, is highly effective but can depress respiration, can reduce myocardial contractility, and is a potent venous vasodilator. Evidence also suggests that morphine interferes with some P2Y12 receptor inhibitor activity. A large retrospective trial also showed that morphine may increase mortality in patients with acute myocardial infarction ( 4, 5 ). Hypotension and bradycardia may also occur secondary to morphine use, but these complications can usually be overcome by prompt elevation of the lower extremities.

Standard therapy for all patients with unstable angina includes beta-blockers, ACE inhibitors, and statins. Beta-blockers are recommended unless contraindicated (eg, by bradycardia, heart block, hypotension, or asthma), especially for high-risk patients. Beta-blockers reduce heart rate, arterial pressure, and contractility, thereby reducing cardiac workload and oxygen demand. ACE inhibitors may provide long-term cardioprotection by improving endothelial function. If an ACE inhibitor is not tolerated because of cough or rash (but not angioedema or renal dysfunction), an may be substituted. Statins are also standard therapy regardless of lipid levels and should be continued indefinitely.

Reperfusion therapy in unstable angina

Fibrinolytic drugs , which can be helpful in patients with STEMI, do not benefit patients with unstable angina.

Angiography is typically done during admission—within 24 to 48 hours of admission if the patient is stable or immediately in unstable patients (eg, with ongoing symptoms, hypotension, sustained arrhythmias). Angiographic findings help determine whether PCI or coronary artery bypass grafting (CABG) is indicated. Choice of reperfusion strategy is further discussed in Revascularization for Acute Coronary Syndromes .

Pearls & Pitfalls

Rehabilitation and post-discharge treatment.

Functional evaluation

Changes in lifestyle: Regular exercise, diet modification, weight loss, smoking cessation

Medications: Continuation of antiplatelets, beta-blockers, ACE inhibitors, and statins

Patients who did not have coronary angiography during admission, have no high-risk features (eg, heart failure, recurrent angina, ventricular tachycardia or ventricular fibrillation after 24 hours, mechanical complications such as new murmurs, shock), and have an ejection fraction > 40% usually should have stress testing of some sort before or shortly after discharge.

The acute illness and treatment of unstable angina should be used to strongly motivate the patient to modify risk factors. Evaluating the patient’s physical and emotional status and discussing them with the patient, advising about lifestyle (eg, smoking, diet, work and play habits, exercise), and aggressively managing risk factors may improve prognosis.

On discharge, all patients should be continued on appropriate antiplatelets, statins, antianginals, and other medications based on comorbidities.

Treatment references

1. Nakayama N, Yamamoto T, Kikuchi M, et al : Prehospital Administration of Aspirin and Nitroglycerin for Patients With Suspected Acute Coronary Syndrome—A Systematic Review.  Circ Rep 4(10):449–457, 2022. doi:10.1253/circrep.CR-22-0060

2. Antithrombotic Trialists' Collaboration : Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients [published correction appears in BMJ 2002 Jan 19;324(7330):141].  BMJ 324(7329):71–86, 2002. doi:10.1136/bmj.324.7329.71

3. Amsterdam EA, Wenger NK, Brindis RG, et al : 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. J Am Coll Cardiol 64 (24):e139–e228, 2014. doi: 10.1016/j.jacc.2014.09.017

4. Kubica J, Adamski P, Ostrowska M, et al : Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial. Eur Heart J 37(3):245–252, 2016. doi: 10.1093/eurheartj/ehv547

5. Meine TJ, Roe MT, Chen AY, et al : Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J 149(6):1043-1049, 2005. doi 10.1016/j.ahj.2005.02.010

Prognosis for Unstable Angina

Prognosis after an episode of unstable angina depends upon how many coronary arteries are diseased, which arteries are affected, and how severely they are affected. For example, stenosis of the proximal left main artery or equivalent (proximal left arterial descending and circumflex artery stenosis) has a worse prognosis than does distal stenosis or stenosis in a smaller arterial branch. Left ventricular function also greatly influences prognosis; the presence of significant left ventricular dysfunction (even with 1- or 2-vessel disease) warrants a lower threshold for revascularization.

Overall, a substantial proportion of patients with unstable angina have a myocardial infarction within 3 months of onset; sudden death is less common (see table Risk of Adverse Events at 14 Days in Unstable Angina or NSTEMI ). Marked ECG changes with chest pain indicate higher risk of subsequent MI or death.

Unstable angina is new, worsening, or rest angina in patients whose cardiac biomarkers do not meet criteria for myocardial infarction.

Symptoms of unstable angina include new or worsening chest pain or chest pain occurring at rest.

Diagnosis is based on serial ECGs and cardiac biomarkers.

Immediate treatment includes oxygen, antianginals, antiplatelets, and anticoagulants.

For patients with ongoing symptoms, hypotension, or sustained arrhythmias, do immediate angiography.

For stable patients, do angiography within 24 to 48 hours of hospitalization.

Following recovery, initiate or continue antiplatelet agents, beta-blockers, angiotensin-converting enzyme inhibitors, and statins.

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Copyright © 2024 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. All rights reserved.

RICHARD SADOVSKY, M.D.

Am Fam Physician. 2002;66(12):2308

Chest pain is considered the major clinical presentation of patients with acute coronary syndromes. The significant number of patients with acute coronary syndrome who do not have chest pain on initial presentation are at risk for receiving less aggressive care. Improved recognition of atypical symptoms of acute coronary syndrome may lead to more rapid treatment. Canto and associates used a retrospective review to determine the proportion of patients admitted with unstable angina pectoris who presented with atypical symptoms and to better characterize atypical presentations of the condition.

The study used data from the Alabama Unstable Angina Study of Medicare beneficiaries, which included patients hospitalized from 1993 to 1999, to review the presenting characteristics of persons with confirmed unstable angina pectoris.

Typical presentation included substernal chest pain and chest pain aggravated by exercise or relieved with rest or nitroglycerin. Atypical presentation was defined as the absence of typical presentation. Atypical presentations ( see the accompanying table ) were noted in more than one half of the 4,167 patient charts reviewed. These patients were less likely to have a history of myocardial infarction or hypercholes-terolemia, or a family history of heart disease, and they were less likely to be admitted with a diagnosis of unstable angina pectoris. These patients also were less likely to receive early aspirin or other antiplatelet agents, or heparin, and they less often received beta-blocker therapy on admission. There was no difference in hospital mortality between patients presenting with typical symptoms compared with patients presenting with atypical symptoms.

The authors conclude that among Medicare beneficiaries with unstable angina pectoris, more than one half have atypical presentations. Persons more likely to present with atypical characteristics include those who are older or female, who have dementia, and who have no history of myocardial infarction or hypercholesterolemia and no family history of heart disease. Physicians should be more aware of these atypical presentations for ischemic disease, especially among the elderly and in women.

Canto JG, et al. Atypical presentations among Medicare beneficiaries with unstable angina pectoris. Am J Cardiol. August 1, 2002;90:248-53.

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Presentation: 'Would interpreting and translating be good careers for you?'

Angela Chenus, certified judiciary and conference French interpreter, will present on interpreting and translating careers. Learn about career options in these growing fields. Bilingual and multilingual students are especially encouraged to join. Light refreshments will be served.

This event, which runs from 11 a.m. to noon, is open to all campus. Sponsored by the Department of World Languages, Literatures, and Cultures and the Academic Initiative Fund.

Augustana College 3750 7th Ave. Rock Island , IL 61201 United States

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2024 Institute for the Humanities Faculty Fellows Presentations

April 30, 2024 11:00 am to 12:00 pm, about this event.

Mississippi State’s Institute for the Humanities is hosting an end-of-year showcase this month highlighting the 2024 IH Faculty Fellows’ scholarship and creativity.

The IH Faculty Fellows Presentation on April 30, 11 a.m., in the College of Arts and Sciences Vault, Allen Hall Room 526, will be livestreamed at  www.facebook.com/msu.humanities.institute .

Fellows will present their year-long book projects in brief 10-minute, audience-friendly talks and will answer questions after. 

Presenters include:

—Jim Giesen, associate professor of history, “The Land of Cotton: Culture and Environment in the American South”

—Peter Messer, associate professor of history, “Dictated by Nature: Science, Theology, and Politics in Early American Natural History”

—Bonnie O’Neill, associate professor of English, “The Good News from Plymouth Church: The Faith, Politics, and Celebrity of Henry Ward Beecher”

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Combining Cryptography and Other Techniques for Various Privacy-Preserving Applications

Description.

Abstract. Secure multiparty computation (SMPC), fully homomorphic encryption (FHE) and differential privacy (DP) is a selection of Privacy-Enhancing Technologies (PETs) that protect input data confidentiality and enable the computation of a function without revealing the input data. Using PETs, one can keep sensitive data private and at the same time derive valuable insights from data analysis, optimizing the privacy-utility tradeoff. In this talk, we will introduce and compare different PETs in order to assist in selecting the most suitable options for a given application and show that they aren't a one-size-fits-all solution. We will present two applications, the first one is genomic data machine learning and second one is financial fraud detection.

Suggested readings: Suggested readings: ia.cr/2021/733 , doi: 10.1007/s00145-023-09464-4 , HyPETs workshop

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Security and Privacy: cryptography

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EQS-News: MorphoSys To Present New Phase 3 MANIFEST-2 Data on Pelabresib in Myelofibrosis in Oral Presentation at 2024 ASCO Annual Meeting

The full text of each abstract will be available on May 23 at 4:00 p.m. CDT. Please refer to the ASCO 2024 online program for full session details and data presentation listings.

About MorphoSys   At MorphoSys, we are driven by our mission: More life for people with cancer . As a global biopharmaceutical company, we develop and deliver innovative medicines, aspiring to redefine how cancer is treated. MorphoSys is headquartered in Planegg, Germany, and has its U.S. operations anchored in Boston, Massachusetts. To learn more, visit us at www.morphosys.com and follow us on Twitter at X and LinkedIn. 

About Pelabresib   Pelabresib (CPI-0610) is an investigational selective small molecule designed to promote anti-tumor activity by inhibiting the function of bromodomain and extra-terminal domain (BET) proteins to decrease the expression of abnormally expressed genes in cancer. Pelabresib is being investigated as a treatment for myelofibrosis and has not been approved by any regulatory authorities. Its safety and efficacy have not been established. 

The development of pelabresib was funded in part by The Leukemia and Lymphoma Society ® .

About MANIFEST-2 MANIFEST-2 (NCT04603495) is a global, double-blind, Phase 3 clinical trial that randomized 430 JAK inhibitor-naïve adult patients with myelofibrosis 1:1 to receive pelabresib in combination with ruxolitinib or placebo plus ruxolitinib. The primary endpoint of the study is a 35% or greater reduction in spleen volume (SVR35) from baseline at 24 weeks. The key secondary endpoints of the study are the absolute change in total symptom score (TSS) from baseline at 24 weeks and the proportion of patients achieving a 50% or greater improvement in total symptom score (TSS50) from baseline at 24 weeks. TSS is measured using the myelofibrosis self-assessment form (MFSAF) v4.0, which asks patients to report the severity of seven common symptoms, rating each of them on a scale from 0 (absent) to 10 (worst imaginable).

Additional secondary endpoints include progression-free survival, overall survival, duration of the splenic and total symptom score response, hemoglobin response rate and improvement in bone marrow fibrosis, among others.

Constellation Pharmaceuticals, Inc., a MorphoSys company, is the MANIFEST-2 trial sponsor.

About Myelofibrosis Myelofibrosis is a blood cancer – belonging to a group of diseases called myeloproliferative neoplasms – caused by genetic abnormalities in bone marrow stem cells and characterized by four hallmarks: enlarged spleen, anemia, impaired bone marrow microenvironment causing fibrosis, and debilitating disease-associated symptoms, including severe fatigue, night sweats, itching, increased bleeding and significant pain caused by their enlarged spleen. For many living with myelofibrosis, the combination of symptoms often severely impacts their quality of life. At diagnosis, several factors, such as age, genetics and bloodwork, help determine a patient’s long-term prognosis. About 90% of newly diagnosed patients have intermediate- to high-risk disease, which has a worse prognosis and a higher likelihood of disease-associated symptoms. While JAK inhibitors, the current standard of care, address some aspects of the disease, no agent provides broad disease control. There is an urgent need for novel, well-tolerated therapeutic options capable of changing the natural course of myelofibrosis to provide patients with deep and durable responses across its four hallmarks.

About Tulmimetostat Tulmimetostat (CPI-0209) is an investigational compound designed to exert anti-tumor activity by inhibiting the function of enhancer of zeste homolog 1 and 2 (EZH1 and EZH2) proteins to reactivate tumor suppressor genes or silencing the oncogenic pathways. Tulmimetostat is being tested as a once-daily oral treatment in a Phase 1/2 trial (NCT04104776) in patients with advanced solid tumors or lymphomas, including ARID1A -mutated ovarian clear cell carcinoma, endometrial carcinoma and other solid tumors, diffuse large B-cell lymphoma, peripheral T-cell lymphoma, BAP1 -mutated mesothelioma and castration-resistant prostate cancer. The primary objectives of the trial include determining the maximum tolerated dose and/or recommended Phase 2 dose and evaluating antitumor activity of tulmimetostat monotherapy. The safety and efficacy of tulmimetostat have not been established.

 For more information, please contact:

24.04.2024 CET/CEST Dissemination of a Corporate News, transmitted by EQS News - a service of EQS Group AG. The issuer is solely responsible for the content of this announcement. The EQS Distribution Services include Regulatory Announcements, Financial/Corporate News and Press Releases. Archive at www.eqs-news.com

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MorphoSys To Present New Phase 3 MANIFEST-2 Data on Pelabresib in Myelofibrosis in Oral Presentation at 2024 ASCO Annual Meeting

Additional ASCO 2024 poster presentation will include new findings from the Phase 2 study of tulmimetostat

PLANEGG and MUNICH, GERMANY / ACCESSWIRE / April 24, 2024 / MorphoSys AG (FSE:MOR)(NASDAQ:MOR) today announced that new efficacy and safety data from the Phase 3 MANIFEST-2 trial of pelabresib, an investigational BET inhibitor, in combination with the JAK inhibitor ruxolitinib in JAK inhibitor-naïve patients with myelofibrosis will be highlighted during an oral presentation on Friday, May 31, at the 2024 American Society of Clinical Oncology (ASCO) Annual Meeting. The congress is being held in Chicago, Illinois, from May 31 to June 4, 2024.

Additionally, new data from the Phase 2 study of tulmimetostat, an investigational next-generation dual inhibitor of EZH2 and EZH1, in patients with advanced solid tumors or hematologic malignancies will be showcased in a poster presentation at ASCO 2024.

ASCO 2024 Presentation Details

The full text of each abstract will be available on May 23 at 4:00 p.m. CDT. Please refer to the ASCO 2024 online program for full session details and data presentation listings.

About MorphoSys At MorphoSys, we are driven by our mission: More life for people with cancer . As a global biopharmaceutical company, we develop and deliver innovative medicines, aspiring to redefine how cancer is treated. MorphoSys is headquartered in Planegg, Germany, and has its U.S. operations anchored in Boston, Massachusetts. To learn more, visit us at www.morphosys.com and follow us on Twitter at X and LinkedIn .

About Pelabresib Pelabresib (CPI-0610) is an investigational selective small molecule designed to promote anti-tumor activity by inhibiting the function of bromodomain and extra-terminal domain (BET) proteins to decrease the expression of abnormally expressed genes in cancer. Pelabresib is being investigated as a treatment for myelofibrosis and has not been approved by any regulatory authorities. Its safety and efficacy have not been established.

The development of pelabresib was funded in part by The Leukemia and Lymphoma Society ® .

About MANIFEST-2 MANIFEST-2 (NCT04603495) is a global, double-blind, Phase 3 clinical trial that randomized 430 JAK inhibitor-naïve adult patients with myelofibrosis 1:1 to receive pelabresib in combination with ruxolitinib or placebo plus ruxolitinib. The primary endpoint of the study is a 35% or greater reduction in spleen volume (SVR35) from baseline at 24 weeks. The key secondary endpoints of the study are the absolute change in total symptom score (TSS) from baseline at 24 weeks and the proportion of patients achieving a 50% or greater improvement in total symptom score (TSS50) from baseline at 24 weeks. TSS is measured using the myelofibrosis self-assessment form (MFSAF) v4.0, which asks patients to report the severity of seven common symptoms, rating each of them on a scale from 0 (absent) to 10 (worst imaginable).

Additional secondary endpoints include progression-free survival, overall survival, duration of the splenic and total symptom score response, hemoglobin response rate and improvement in bone marrow fibrosis, among others.

Constellation Pharmaceuticals, Inc., a MorphoSys company, is the MANIFEST-2 trial sponsor.

About Myelofibrosis Myelofibrosis is a blood cancer - belonging to a group of diseases called myeloproliferative neoplasms - caused by genetic abnormalities in bone marrow stem cells and characterized by four hallmarks: enlarged spleen, anemia, impaired bone marrow microenvironment causing fibrosis, and debilitating disease-associated symptoms, including severe fatigue, night sweats, itching, increased bleeding and significant pain caused by their enlarged spleen. For many living with myelofibrosis, the combination of symptoms often severely impacts their quality of life. At diagnosis, several factors, such as age, genetics and bloodwork, help determine a patient's long-term prognosis. About 90% of newly diagnosed patients have intermediate- to high-risk disease, which has a worse prognosis and a higher likelihood of disease-associated symptoms. While JAK inhibitors, the current standard of care, address some aspects of the disease, no agent provides broad disease control. There is an urgent need for novel, well-tolerated therapeutic options capable of changing the natural course of myelofibrosis to provide patients with deep and durable responses across its four hallmarks.

About Tulmimetostat Tulmimetostat (CPI-0209) is an investigational compound designed to exert anti-tumor activity by inhibiting the function of enhancer of zeste homolog 1 and 2 (EZH1 and EZH2) proteins to reactivate tumor suppressor genes or silencing the oncogenic pathways. Tulmimetostat is being tested as a once-daily oral treatment in a Phase 1/2 trial (NCT04104776) in patients with advanced solid tumors or lymphomas, including ARID1A -mutated ovarian clear cell carcinoma, endometrial carcinoma and other solid tumors, diffuse large B-cell lymphoma, peripheral T-cell lymphoma, BAP1 -mutated mesothelioma and castration-resistant prostate cancer. The primary objectives of the trial include determining the maximum tolerated dose and/or recommended Phase 2 dose and evaluating antitumor activity of tulmimetostat monotherapy. The safety and efficacy of tulmimetostat have not been established.

For more information, please contact:

SOURCE: MorphoSys AG

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