Abnormal lie and breech presentation

Question 1

What are the different foetal lies?

Answer 1

Longitudinal lie - cephalic or breech
Transverse lie
Oblique lie

Question 2

What can cause a foetal lie to not be cephalic?

Answer 2

Too much room:
High parity - lax uterus
Polyhydramnios

Prevent turning:
Foetal abnormalities
Uterine abnormalities
Twins

Prevent engagement:
Pelvic tumours
Placenta praevia

Question 3

Is preterm or term labour more likely to be complicated by breech presentation? Why?

Answer 3

Abnormal lie is more common earlier in pregnancy before term. Therefore, a pregnancy before term is likely to be more complicated as a result of abnormal lie.

Question 4

What are abnormal lies?

Answer 4

Transverse and oblique are abnormal.

Cephalic and breech are normal.

Question 5

What are the different types of breech position? Describe them.

Answer 5

1. Extended breech - both legs extended at the knee
2. Flexed breech - both legs flexed at the knee
3. Footling breech - one or both feet present below the buttocks.

Question 6

What is the management of transverse of unstable lie both before and after 37 weeks?

Answer 6

<37 weeks = no action required.

> 37 weeks = admission incase of membrane rupture and to check for causes such as placenta praevia or polyhydramnios.
ECV is not used before foetus turns back.
An abnormal lie will usually stabilise before 41 weeks.

Question 7

What is unstable lie?

Answer 7

A continually changing lie.

Question 8

What happens when a woman goes into labour with abnormal lie or 41 weeks is reached?

Answer 8

Caesarian section.

Question 9

When is breech diagnosis considered important?

Answer 9

After 37 weeks.

Question 10

What pathologies cause a foetal lie to be breech?

Answer 10

Conditions that prevent movement such as foetal and uterine abnormalities and twin pregnancies.
Conditions that prevent engagement such as placenta praevia, pelvic tumours and pelvic deformities.

All these conditions are important to try and rule out by ultrasound.

Question 11

What is the management for breech presentation?

Answer 11

EVC

If this fails, mode of birth can be caesarian or planned breech birth.

Question 12

What is external cephalic version used for?

Answer 12

To turn the baby to cephalic presentation.

Question 13

What technique is used in ECV?

Answer 13

1. Both hands on abdomen.
2. Breech is disengaged from the pelvis - pushed upwards and to the side.
3. Rotation in the form of a forward summersault is attempted.
   Performed under ultrasound guidance.

Question 14

What guidance is used in ECV and why?

Answer 14

US.

Incase of complications and to allow immediate delivery if they occur.

Question 15

What is done immediately after ECV?

Answer 15

CTG monitoring.

Anti-D in those women who require it.

Question 16

How safe is EVC? What are the risk factors?

Answer 16

Very safe.

Risk is low, but include placental abruption and uterine rupture.

Question 17

What affects the success of EVC?

Answer 17

Lower success rates are seen in women with:

• Nulliparous
• Caucasian
• Breech is engaged
• Low liquor volume
• Unable to feel the head easily
• High uterine tone
• Obesity.

Question 18

What are the contraindications to ECV?

Answer 18

Twins
Vaginal delivery is contraindicated - placenta praevia
Foetal compromised
Membranes have ruptured
Previous antenatal bleeding - suggests placenta abruption.

Question 19

What are the delivery options for breech presentation?

Answer 19

Caesarian section at 39 weeks.

Planned vaginal breeched birth (40 weeks).

Question 20

What weight is the upper limit for breech vaginal delivery?

Answer 20

3.8kg

Question 21

When is pushing in breech delivery discouraged until?

Answer 21

Discouraged until the buttocks are visible.

Question 22

When is caesarian section advised during birth?

Answer 22

Slow cervical dilatation in the first stage or poor descent in the second stage.

Question 23

What is used to monitor the baby during breech birth?

Answer 23

CTG

Question 24

What steps are used in a breech vaginal birth?

Answer 24

1. No maternal pushing until buttocks are visible.
2. Once buttocks distend the perineum, episiotomy can be made but is not essential.
3. Foetus delivers as far as the umbilicus with maternal effort.
4. Legs are flexed out the vagina whilst the foetal back is still anterior.
5. Once scapular is visible, the anterior and then posterior arms are hooked down by a finger over the shoulder, sweeping across the chest.
6. When the back of the neck is visible, the operator supports the entire weight of the foetus on one palm and one forearm, with their finger in its mouth to guide the head over the peritoneum and maintain flexion. The other hand presses on the occiput.

Question 25

What is the Lovset’s procedure used for?

Answer 25

When the arms are outstretched in vaginal breech delivery and cannot be hooked, this is used to get the shoulders out. The foetus is turned 180* clockwise and then anti-clockwise with gentle downward traction, whilst holding the body with thumbs on sacrum.

Question 26

What is the Mauriceau-Smellie-Veit manoeuvre used?

Answer 26

When the back of the neck is visible, the operator supports the entire weight of the foetus on one palm and one forearm, with their finger in its mouth to guide the head over the peritoneum and maintain flexion. The other hand presses on the occiput.