6.1 - Breech - Exam Flashcards
Exam: Identify factors that contribute to breech presentation at term
Uterine abnormalities
- fibroids
- bicorn uterus
(no room)
Placental implantation
- praevia
(unable to move cephalic)
- short umbilicus
Fetal abnormalities
- FGR
- Malformations
Prematurity
(hasn’t moved to cephalic as yet)
- multiples (less room to move)
Exam: Describe the abdominal palpation findings of a breech presentation and possible variations of
breech presentation
- fetus not engaged
- fetal head palled at the top of the funds
- Abdominal palpation: if the presenting part is irregular and not ballotable or if the fetal head is ballotable at the fundus
- FHR found uper abdo instead of lower/middle of the uterus
Three different types of breech
- Frank Breech - the bottom is coming first, legs straight up, thighs against body and feet near the ears
- Compete Breech - Where the feet and bottom coming first and the knees are bent
- Footling Breech - where one or two of the feet are the presenting part (emergeny c-section)
-
Exam: Describe the options available to women who have a term breech presentation
- c-section if baby in favourable position (not footling)
- NVB however would need experience obstetricians and senior midwives present
- USS to confirm
- Offer ECV External Cephalic - >37 weeks
Version (ECV) if there are no contraindications at 37 weeks. - If ECV is declined or unsuccessful, provide counselling on risks and benefits of a planned vaginal birth versus an ELCS.
- Inform the woman that there are fewer maternal complications with a successful vaginal birth, however the risk to the woman increases significantly if there is a need for an EMCS.
Inform the woman that caesarean section increases the risk of complication in future pregnancies, including the risk of a repeat caesarean section and the risk of invasive placentation.
If the woman chooses an ELCS, document consent and organise booking for 39 weeks gestation.
Contraindications
Table 1. Contraindications to ECV
Ruptured membranes
Placental abruption
Severe pre-eclampsia
Abnormal cardiotocograph (CTG)
Lack of maternal consent
Current or recent (within one week) vaginal bleeding
Any absolute indication for caesarean section
Multiple pregnancy (except after delivery of the first twin)
Scarred uterus
Placenta praevia
Rhesus isoimmunisation
Abnormal fetal Doppler
Lack of access to ultrasound
Lack of equipment or personnel to perform fetal monitoring
Lack of capability to perform emergency caesarean section
Exam: Describe the midwife role in facilitating a spontaneous vaginal breech birth
- experienced midwife
- Fetal - CTG continuous
- intermittent if coninuous is refused
- Have the woman in the optimal position for birth is upright
- Analgesia - epidural may increase the risk of intervention with a vaginal breech birth
- Epidural may impact on the woman’s ability to push spontaneously in the second stage of labour
*
First stage
*Manage with the same prinincples as a cephalic presentation - Labour should be expected to progress as for a cephalic presentation
- if first stage of labour is slow - consider c-section
- if epi insitu and contractions are less than 4:10 escalate care
- Avoid routine amniotomy to avoid the risk of cord prolapse or compression
Second stage
* Allow passive descent of the breech to the perineum prior to active pushing
* if breech is not visible within one hour of passive descent a c-section is normally recommended
* Active second stage should be 1/2 hour with multi and 1 hour with primipara
* all midwives and obstetricians should be familar with the technique and maneouvres required to assist NVBB
* Ensure a consultant is present for the birth
* Ensure a senior paediatric clinincal is present for birth
*
Birth
* Encouragement of maternal pushing (if at all) should not begin unitl the presenting part is visable
* a hands off approach is recommended
* signigicant cord compression is common once the buttocks have passed the perineum
* timely intervention is recommended if there is slow progress once the umbilcus has been delivered
* Allow spontaneous birth of the trunk and limbs by maternal effort as breech extraction can cause extension of the arms and head
* Grasp the fetus around the bony pelvic girdle, not on soft tissue to avoid trauma
* Assist birth if there is a delay of more than five minutes from delivery of the buttocks and head , or of more than three minutes from the umbilicus to the head
* signs that delivery should be expiedited also include lack of tone or colour or signs of poor fetal condition
* Ensure fetal back reamins in the anterior position
* routine expisotomy is not required
* reverse loveset’s manoeuvre many be used to reduce nuchal arms
* supra-pubic pressure may aide flexion of the head
* Maricueau-smellie-veit manoeuvre or forceps may be used to deiver the after coming head
Exam: Explain the possible complications of breech birth that may arise and the impact that this has on
birthing choices for women.
- Entrapment of the fetal head
- a VE should be performed to ensure that the cervix is fully dilated
- if the fetal head has entered the pelvis, perform the mauriceau-smellie-veit manoevre combined with suprapubic pressure from a second attendant in a direction that maintains flexion and descent of the fetal head
- Rotate fetal body to a lateral position and apply suprapubic pressure to flex the fetal head, if unsuccessful consider alternative manoeuvre
- reassess cervical dialtation, if not fully dilated consder dhurssen incision at 2, 10 and 6 oclock
- a c-section may be performed if the baby is still alive
- Hypoxia
- Cord prolaspe
- Hip dysplaysia
- head trauma
- facial trauma
- PPH
- longer labour
- higher injury on perineal trauma or dhurssen incision
Exam:What are the possible variations to the breech presentation?
Three different types of breech
- Frank Breech - the bottom is coming first, legs straight up, thighs against body and feet near the ears
- Compete Breech - Where the feet and bottom coming first and the knees are bent
- Footling Breech - where one or two of the feet are the presenting part (emergeny c-section)
- Kneeling - Knees are the lowest part presenting
Exam: What implications does this have on
the suitability for vaginal birth?
can deliver with frank and complete breech
footling breech is a c-section
Exam: How would you assess for these variations?
- abdo palp
- VE
- formal or beside U/S
*spectlum visiablity of the presenting part
Exam: List 6 factors that would predispose a woman to a breech presentation.
MATERNAL
* Nulliparity
* Previous breech birth
* Uterine (anatomical) anomaly
* Placental abnormalities (praevia, cornual) Oligohydramnios
* Polyhydramnios
* Multiple pregnancy
* Grand multiparity
FETAL
Extended fetal legs
Short umbilical cord
Early gestation
Fetal abnormality
Poor fetal growth
Exam: What are the options to manage a breech presentation? What would influence the decision
making?
- aim for spontanous delivery
- Discuss and plan mode of delivery for breech presentation in partnership with the woman
- Women should be informed about the higher perinatal risks associated with breech birth and with vaginal breech birth in particular (relative risk = 3:1)
- Consider the size of previous babies born vaginally relative to the current estimation of fetal weight
- Clinical assessment of pelvic capacity by vaginal examination
- Precipitate labour that does not allow time for caesarean section
- Undiagnosed breech presentation
- Delivery of the second twin in breech position
- the woman chooses to deliver vaginally and has an agreed management plan (including conditions for abandonment of vaginal birth) with a registrar or consultant who is experienced in vaginal breech birth. Verbal consent is documented
- Considerations:
Exclude intrauterine growth restriction
Fetal weight is greater than 2,500 g and less than 4,000 g
Presentation should be either complete or frank breech
Exclude hyperextended head
No previous caesarean section
Intrapartum considerations:
Aim for spontaneous onset of labour
Group and hold, fbe, coagaugs
Ensure caregiver is appropriately experienced
Continuous electronic fetal monitoring is advised
Regular assessment to confirm adequate progress
Fetal blood sampling from the buttocks during labour is NOT advised
Epidural analgesia should NOT be routinely advised; offer women a choice of analgesia during breech labour and birth2
Induction or augmentation ONLY in selected cases. Decision to be made by consultant
Maternal co-operation with pushing
Aim for an assisted breech birth
Anaesthetist and paediatrician present at birth
Prompt evaluation and recourse to immediate caesarean section in the presence of significant fetal compromise
Exam: Who are skilled health professionals required to conduct a breech birth safely? What are their
roles?
- senior obstretrican
- senior pedatrician
- two senior midwives
*
Exam: Write up the mechanism of this breech birth. (Remember the principles of the mechanism of
birth regardless of denominator?)
Descent
Anterior buttocks hits the plevic floor
Flexion
the increasing compacted so limbs can increase flexion
Internal rotation
rotates 45% towards the right side of the pelvic to lie directly under the SP
bitrochanteric diameter of 10cms in the anterior posterior position
Crowning
the anterior buttock escapes under the SP and the posterior buttocks swips the perineum
bilateral flexion the buttocks is born
External rotation
Restitution
Restituion occurs buttock turns slightly to the womans right side
Internal rotation
shoulders enter the pelvis in the L) oblique and the left shoulder rotates forwards 45% along the right side of the pelvis and escapes under the SP. the posterior shoulder sweeps the perineum and the shoulders are born
External rotation
head enters the pelvis
the sagitttal stutures are in the trasverse diameter of the pelvic brim
the occiput rotates forward to the L) side
the suboccipital region is under the SP
Body externally rotates so the back in the upper most
position
Chin face & synicept is born
Exam: At what gestation is ECV considered? What are the possible complications? What is the midwife
role following ECV? ( text book content)
from 37 weeks
External cephalic version (ECV)
All women with uncomplicated breech presentation at or near term should be offered ECV unless contraindications exist (see contraindications below)
Studies have shown no effect from the use of postural techniques such as the knee-chest Elkins procedure to correct the position of the baby from breech to cephalic4
The use of tocolysis with salbutamol has been shown to increase the success rate of ECV. Salbutamol may be routinely used for ECV or if an initial ECV attempt has failed5
Women should be counselled that, with a trained operator, an overall ECV success rate of 40 % for nulliparous and 60 % for multiparous women can usually be achieved5
With ECV, appropriate selection of women and adequate surveillance are necessary to ensure a low complication rate
The highest ECV success rates are seen with multiparous non-white women with a relaxed uterus, where the breech is not engaged and the head is easily palpable5
Contraindications to ECV
Antepartum haemorrhage in current pregnancy
Ruptured membranes
Multiple pregnancy
Severe fetal abnormality
Caesarean section necessary for other indications
Previous caesarean section (relative contraindication)
Poor fetal growth
Significant hypertension or preeclampsia
Uterine anomaly
Cord around fetal neck (nuchal cord)
Abnormal cardiotocograph (CTG)
Hyperextension of the head
The risks to the mother of ECV are exceedingly small and relate to possible effects from tocolysis and the rare complication of placental abruption
For the fetus at term the risks are small if carried out with adequate surveillance by skilled personnel and with theatre facilities for immediate intervention in the event of a complication
Guideline for ECV
On admission
Ensure verbal consent obtained Abdominal palpation
Review blood group
Maternal / fetal observations
Record pulse and blood pressure Record a CTG
Senior medical review:
Confirm breech presentation and absence of a nuchal cord by ultrasound
Consider intravenous access if salbutamol tocolysis is required (see salbutamol tocolysis)
Breech confirmed and CTG normal
ECV should be conducted by an experienced person
CTG for 30 minutes after the attempt
Ultrasound to confirm success / exclude cord presentation
ECV unsuccessful
Consider salbutamol tocolysis if due to uterine tone
If ECV still unsuccessful with tocolysis, book elective LSCS
Anti D
A dose of 625 IU CSL Rh D immunoglobulin should be administered to all Rhesus negative women with no pre-existent endogenous anti-D
Discharge
When the CTG after ECV has been reviewed as normal, the woman may be discharged Salbutamol tocolysis
Continuous CTG during procedure
Preparation
Exclude a history of maternal cardiac disease or arrhythmia / untreated thyrotoxicosis Dosage and administration
Obstetric salbutamol: 5 mL ampoule 5 mg / 5 mL
Using a 1 mL syringe, draw up 0.25 mL (250 micrograms) of salbutamol
Add to a 10 mL syringe and make up to 10 mL with sodium chloride 0.9 % (25
micrograms per mL)
Give intravenous salbutamol slowly in 50 microgram boluses up to 250 micrograms in total (often 100 micrograms will be sufficient)
Ensure monitoring of maternal pulse whilst bolus doses are administered
Stop IV administration if maternal pulse > 140 Side effects
Fetal and maternal tachycardia, maternal hypotension, ventricular ectopics, supra- ventricular tachycardia, ventricular fibrillation, pulmonary oedema, hypoxia – secondary to increased oxygen demands + / - fluid shift in lungs, hyperglycaemia
Exam: Why is it that most breech births are now conducted as an elective caesarean section in
developed countries? Is this in line with current evidence?
to reduce perinatal and neonatal mortality rates
decrease in skill set to deliver breech birth
risk of litigation if anything goes wrong
Exam:
mechanism of birth
Exam: Loveset Manoeuvre
- this is a maneuvre to rotate the anterior shoulder underneath the symphsis and engage the arm
- deliver the anterior arm
- then do a 180 Degree counter-rotation
- this engages the posterior arm
- which is then delivered
*
Exam: Mauriceau Smellie Veit
the accoucheur allows the baby to straddle their dominant arm
provides flexion and control the emergence of the baby’s head
the fingers of the non dominant had aid flexion
place ring and forefingers are placed on the baby’s shoulders and the middle finger is place on the occiput
place the fore and middle fingers of the support hand are placed on the baby’s malar bone
fingers of the arm provide flexion
as the accoucher stands up
the baby is delivered in an arc towards the mothers abdomen
the assisstance may use supra pubic pressure to aid flexion
