Assisting labour

Question 1

What is a breech?> how common is it?

Answer 1

caudal end of the fetus occupies the lower segment. Whilst around 25% of pregnancies at 28 weeks are breech it only occurs in 3% of babies near term

Question 2

What is the difference between frank and footling breeck?

Answer 2

A frank breech is the most common presentation with the hips flexed and knees fully extended. A footling breech, where one or both feet come first with the bottom at a higher position, is rare but carries a higher perinatal morbidity

Question 3

Risk factors for breech?

Answer 3

• uterine malformations, fibroids
• placenta praevia
• polyhydramnios or oligohydramnios
• fetal abnormality (e.g. CNS malformation, chromosomal disorders)
• prematurity (due to increased incidence earlier in gestation)

Question 4

Management of breech?

Answer 4

• 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

Question 5

how can you help counsel women on breech decisions?

Answer 5

• ‘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 6

Indications for C section?

Answer 6

• absolute CPD
• placenta praevia grades 3/4
• pre-eclampsia
• post-maturity
• IUGR
• fetal distress in labour/prolapsed cord
• failure of labour to progress
• malpresentations: brow
• placental abruption: only if fetal distress; if dead deliver vaginally
• vaginal infection e.g. active herpes
• cervical cancer (disseminates cancer cells)

Question 7

What are the serious risks in C section?

Answer 7

Maternal:
•emergency hysterectomy
•need for further surgery at a later date, including curettage (retained placental tissue)
•admission to intensive care unit
•thromboembolic disease
•bladder injury
•ureteric injury
•death (1 in 12,000)

Future pregnancies:
•increased risk of uterine rupture during subsequent pregnancies/deliveries
•increased risk of antepartum stillbirth
•increased risk in subsequent pregnancies of placenta praevia and placenta accreta)

Question 8

What are the frequent risks of c section?

Answer 8

Maternal:
•persistent wound and abdominal discomfort in the first few months after surgery
•increased risk of repeat caesarean section when vaginal delivery attempted in subsequent pregnancies
•readmission to hospital
•haemorrhage
•infection (wound, endometritis, UTI)

Fetal:
•lacerations, one to two babies in every 100

Question 9

What are the issues around vbac?

Answer 9

• If a women has had a previous caesarean section due a factor such as fetal distress the majority of obstetricians would recommend a trial of normal labour
• around 70-75% of women in this situation have a successful vaginal delivery
• contraindications include previous uterine rupture or classical caesarean scar

Question 10

Indications for forceps?

Answer 10

• fetal distress in the second stage of labour
• maternal distress in the second stage of labour
• failure to progress in the second stage of labour
• control of head in breech deliver

Question 11

Indications for induction of labour?

Answer 11

• prolonged pregnancy, e.g. > 12 days after estimated date of delivery
• prelabour premature rupture of the membranes, where labour does not start
• diabetic mother > 38 weeks
• rhesus incompatibility

Question 12

In what ways can we start labour?

Answer 12

• membrane sweep
• intravaginal prostaglandins
• breaking of waters
• oxytocin