5.4 Breech Flashcards
Define Malpresentation
Any non-cephalic part presenting first (on cervix)
Define Breech presentation
Fetus presenting bottom first
Give the 3 types of Breech presentation
Which type is the most common?
Which type is contraindicated for vaginal delivery?
Complete (10%): Hip and knee flexed
Footling (20%): One or both feet tucked underneath buttocks (VD contraindicated)
Frank (70%): Hips flexed, knee extended
Give 5 Risk factors for Breech Presentation
1) Chance
2) Obstruction to outlet (Low lying fibroid, placenta previa, ovarian cyst)
3) Polyhydramnios
4) Multiple pregnancy
5) Uterine anomaly (Mullerian duct anomalies e.g. Bicornuate uterus)
6) Fetal anomaly
What are the consequences of breech presentation?
Perinatal morbidity and mortality
Entrapment: Delayed 2nd stage of delivery => perinatal asphyxia => Hypoxic ischemic injury such as encephalopathy => Cerebral palsy/mental delay
What are the management options for breech presentation?
ECV - Extracephalic presentation
Vaginal breech delivery -> Assisted delivery
C-section
When is ECV performed?
What is its success rate?
Performed at 36 weeks with a 50% success rate
What is ECV?
Explain how it is performed in full
External cephaloversion is the manipulation of a foetus through maternal abdomen in an attempt to turn it from a breech presentation to a cephalic presentation. This is done by administering tocolysis + Anti-D. The physician will begin by identifying the head and rump of the baby externally before applying pressure to turn in an attempt to have cephalic presentation, engaged in the pelvis.
Give 5 complications/risks of ECV
Give 5 Contraindications
Complications:
1) Rupture of membranes
2) Fetomaternal hemorrhage
3) Placental abruption
4) Emergency C-section
5) CTG abnormalities
Contraindications:
1) Ruptured membrane (=> if mother presents already in labour it cannot be performed)
2) Recent vaginal bleed
3) Rhesus isoimmunisation
4) Any absolute indication for a C-section (e.g. cephalo-pelvic disproportion, Prolonged ROM)
5) Abnormal CTG
6) IUGR
7) Previous C-section
90% of breech babies are delivered by C-section. Part of it is due to the strict requirements for consideration of breech vaginal delivery. What are they?
1) Foetal weight <3800g
2) Complete or Frank Breach (Not footling)
3) Spontaneous onset of labour
4) No other pregnancy complications
5) Skilled obstetrician for procedure
What is the protocol for Assisted breech delivery?
As in what should you do?
1) Avoid using induction agents
2) Buttocks delivered with maternal effort
3) Lovset manoeuvre to rotate and deliver shoulders
4) Use forceps! or MSV! manoeuvre to deliver the head
What is the Lovset Manouvre
Woodscrew but holding buttocks (one hand on either side of buttocks, and rotated to deliver shoulders)
What is the MSV manoeuvre?
Maricean-smellie-veit manouvre
After delivery of the shoulders, the head is left one hand on back with middle finger on occiput and other hand in mouth of baby. The assistant would also be providing supra-pubic pressure.
At 28 weeks gestation, What % of babies are in breech position? How about at term? What is the cause of this discrepancy?
28 weeks ->20%
At term -> 2-3%
Most babies who are in this position will turn on their own to cephalic presentation later in pregnancy
If the patient (breech presentation) opts for C-section, when is the baby delivered?
39 weeks
