Compound Presentation

Compound presentation is a presentation in which a hand, arm or foot lies beside the presenting part (usually the head) at the pelvic inlet. Prematurity, grand multiparity, polyhydramnios, twin pregnancy, early rupture of membranes and a pelvic mass allow a limb to lie beside the head. Most cases resolve as the head descends, but cord prolapse and obstructed labour can occur.

• Risk factors: prematurity, multiparity, polyhydramnios, multiple pregnancy, small fetus, contracted pelvis, pelvic tumour.
• Hand beside the head is the commonest form.
• Foot and head together are rarer and carry a higher risk of obstruction.

Labour may be normal with delay in descent, and the limb is found on vaginal examination beside the head or in front of it. The fetal heart may show variable decelerations if the cord is also prolapsed.

• Fingers or a small hand felt beside the fontanelle or the face.
• Slow progress in the first or second stage.
• Differential diagnosis: cord prolapse, face presentation, breech with footling, shoulder presentation, occiput posterior position, cephalopelvic disproportion.
• Complications: cord prolapse, obstructed labour, prolonged labour, fetal distress, uterine rupture, fracture or nerve injury of the prolapsed limb, caesarean section, perineal tear.

The diagnosis is made by vaginal examination in labour and confirmed by ultrasound.

• Vaginal examination: limb (fingers, hand, forearm or foot) beside the head, with the head at its usual position; check the cord by feeling for pulsation.
• Ultrasound: head with a limb adjacent to the cervix, lie, liquor volume, estimated fetal weight.
• Cardiotocography; maternal pulse and temperature.
• Pelvic assessment for contraction.

The principle is to allow labour while progress is normal, to avoid pushing the limb down, and to deliver by caesarean section for cord prolapse, fetal distress or arrest.

• Supportive: continuous cardiotocography; do not pull or push the limb; maternal position on the side of the prolapsed limb or knee chest position; empty the bladder; Ringer's lactate 1 litre IV over 2 hours; check the cervix 2-hourly; call a senior obstetrician.
• Pharmacological: analgesia (epidural, or pethidine 50 to 100 mg IM 4-hourly); cefazolin 2 g IV as a single dose before caesarean section; terbutaline 0.25 mg subcutaneous once while preparing for theatre if the cord has prolapsed; oxytocin 10 IU IM after birth, then 20 IU in 1 litre Ringer's lactate at 125 mL per hour for 4 hours; newborn vitamin K 1 mg IM.
• Procedures: vaginal birth when the limb retracts and descent is normal; an experienced operator may push the hand up gently between contractions with the mother in the knee chest position if it blocks descent; caesarean section for cord prolapse, fetal distress, a foot with the head, or failure to progress.
• Red flags: palpable cord, fetal bradycardia or variable decelerations, no descent over 2 hours, bandl ring, bleeding.
• Follow-up: newborn examination of the limb for bruising, fracture and nerve injury; paediatric review if movement is reduced; review at 6 weeks.