Abnormal Lie & Breech Presentation

Question 1

What is the lie of the fetus?

Answer 1

The relationship of the fetus to the long axis of the uterus, if is lying longitudinal within the uterus, the lie is longitudinal

Question 2

Is preterm labour more commonly complicated by an abnormal lie than normal labour?

Answer 2

Yes, earlier in the pregnancy abnormal lie is more common

Question 3

What are the risk factors for abnormal lie?

Answer 3

Preterm labour; circumstances that allow more room to turn (polyhydramnios, high parity); conditions that prevent turning (fetal or uterine abnormalities or twins); conditions that prevent engagement (placenta praevia)

Question 4

What are the complications of abnormal lie?

Answer 4

Engagement cannot occur and the arm or the umbilical cord may prolapse when the membranes rupture, and if neglected the obstruction eventually causes a uterine rupture.

Question 5

How do you manage abnormal lie?

Answer 5

Before 37 weeks it is normal unless the woman is in labour. After 37 weeks the women is normally admitted and causes are identified. If spontaneous version occurs for more than 48h mother is discharged.

Question 6

What is the fetal presentation?

Answer 6

The presentation refers to the part of the fetus that occupies the lower segment of the uterus or the pelvis.

Question 7

What is breech presentation?

Answer 7

Presentation of the buttocks

Question 8

What is extended (frank) breech presentation?

Answer 8

Both legs extended at the knee

Question 9

Is extended (frank), footling or flexed (complete) breech presentation more common?

Answer 9

Extended breech (70%), then flexed (15%) and footling (15%)

Question 10

What is footling breech?

Answer 10

One of both feet present below the buttocks

Question 11

What are the clinical features of a breech presentation?

Answer 11

Upper abdominal discomfort is common; the hard head is normally palpable and ballotable at the fundus

Question 12

What are the complications of a breech presentation?

Answer 12

Perinatal and long-term morbidity and mortality are increased. Fetal abnormalities are more common, higher rates of long-term neurological handicap. Increased risk of cord prolapse. The after-coming of the head may get trapped, which could lead to fetal death

Question 13

How do you manage breech presentation?

Answer 13

If < 36 weeks:

• Many fetuses will turn spontaneously
• If still breech at 36 weeks NICE recommend external cephalic version (ECV)- this has a success rate of around 60%. The RCOG recommend ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women
• If the baby is still breech then delivery options include planned caesarean section or vaginal delivery

Information to help decision making - the RCOG recommend:
‘Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth.’
‘Women should be informed that there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born.’

Question 14

What are the factors that affect the success of ECV?

Answer 14

Lower success rates in nulliparous, caucasian, where the breech is engaged or head not easily palpable; uterine tone is high; obese women; liquor volume is reduced

Question 15

What are the absolute contraindications to ECV?

Answer 15

1. where caesarean delivery is required
2. antepartum haemorrhage within the last 7 days
3. abnormal cardiotocography
4. major uterine anomaly
5. ruptured membranes
6. multiple pregnancy