Breech Flashcards
when the buttocks or legs of the fetus enter the pelvis before the head
Breech presentation
true/false
In breech presentation, it is more common when remote from term
True
In breech presentation, it is more common when REMOTE from term
persists AT TERM in 3-5% of singleton pregnancies
Breech presentation
why would the fetus want to present as breech and not the normal cephalic position?
Breech or buttocks will be LARGER in diameter compared to the biparietal diameter of the head
3 categories of breech presentation
- frank breech
- complete breech
- incomplete breech
BUTTOCKS: present in the introitus
THIGHS: flexed towards the lower abdomen
LEGS: extended
FEET: close to the face
Frank breech
BUTTOCKS: present in the introitus
THIGHS: flexed towards the lower abdomen
LEGS: extended
FEET: close to the face
“Indian sit”
Complete breech
THIGHS: flexed towards the lower abdomen
LEGS: flexed towards the thighs
Complete breech
THIGHS: flexed towards the lower abdomen
LEGS: flexed towards the thighs
One or both THIGHS: flexed or extended
One FOOT: extended
Incomplete breech/ Footling breech
One or both THIGHS: flexed or extended
One FOOT: extended
Reference point of all types of breeches
Sacrum
Give 2 types of breech presentation where the sacrum is very easy to palpate
Frank and Complete
Different positions of the presenting part
Right or Left, Anterior Sacrum or Sacro-anterior
presenting part of both Frank and complete breeches
Sacrum
What is the station if the sacrum is palpated at the level of the ischial spine
Station= 0
- incomplete breech
True/False
Even if the foot is palpated on IE, the point of reference would be still the sacrum
True
Even if the foot is palpated on IE, the point of reference would be still the sacrum
*the sacrum is high in incomplete breech presentation
4 Risk factors of Breech presentation
- GREATER intrauterine surface area
- Congenital Anomaly
- DECREASE surface surface area at the LOWER uterine segment
- Prior occurrences of Breech delivery and CS delivery
Conditions wherein there is a GREATER intrauterine surface area
GREATER intrauterine surface area:
- Gestational age (premature)
- Abnormal amniotic fluid volume
- High parity with uterine relaxation
*There will be more room for the fetus to turn into cephalic-breech-transverse
Congenital anomalies of the head that would present as breech
- Hydrocephaly
- Anencephaly
*confers a larger podalic pole, seeks the more spacious fundal pole and therefore, would present as breech
Conditions with DECREASED surface area at the lower uterine segment
- Multifetal gestation
- Fundal placental implantation
- Uterine/Mullerian anomalies
- Pelvic tumors (block the LUS)
- Placenta previa (block the LUS)
Examples of Uterine/ Mullerian anomalies
Bicornuate uterus and Uterine didelphus
Maneuver used for abdominal examination
Leopold’s maneuver
identifies fetal lie and which fetal pole occupies the fundus
L1 (fundal grip)
L1= large, ballotable, nodular mass
Breech presentation
L1= large, ballotable, nodular mass (head)
ballotable- when you tap in the head over abdomen, the head would bounce back.
L1= hard, round and more mobile
Cephalic presentation
L1= hard, round and more mobile
maneuver to determine fetal orientation
L2 (Lumbar grip)
determines fetal back (resistant part) and fetal extremities (numerous, small, mobile parts)
L2(Lumbar grip)
true/false
At L2, breech is the same w/ cephalic, the fetal back on one side of the abdomen and fetal small parts on the
other will be felt.
true
At L2, breech is the same w/ cephalic, the fetal back on one side of the abdomen and fetal small parts on the
other will be felt.
confirms fetal presentation
L3 (Pawlick’s Grip)
thumb and fingers of one hand grasp the lower part of the abdomen above the symphysis pubis
L3(Pawlick’s Grip)
L3= hard, round, and more mobile part
Breech presentation
L3= hard, round, and more mobile part
L3= Large, ballotable, nodular mass (Head)
Cephalic presentation
L3= Large, ballotable, nodular mass (Head)
true/false
At L3, The breech is NOT MOVABLE above the pelvic inlet if engagement has NOT occurred
False
L3: The breech is MOVABLE above the pelvic inlet if engagement has NOT occurred. The intertrochanteric diameter of the fetal pelvis has NOT passed through the pelvic inlet
degree of descent
L4 (Pelvic Grip)
examiner facing the feet of the mother, places the fingertips of both hand on the presenting part
L4 (Pelvic Grip)
True/False
At L4, after engagement, the firm breech is beneath
the symphysis.
True
Fetal heart sounds is heard loudest SLIGHTLY ABOVE THE UMBILICUS (upper segment).
Breech
It is because the head is up with the upper torso.
Fetal heart sounds is heard loudest at the LUS
Cephalic
The ischial tuberosities, sacrum and anus usually are palpable
Frank Breech
After further descent, the external genitalia may be distinguished
Frank Breech
The ANUS may be mistaken for the mouth, and the ISCHIAL TUBEROSITIES for the molar eminences.
Frank Breech
The finger encounters muscular resistance with the anus, and upon removal from the anus, it is sometimes stained with meconium.
Frank Breech
Triangular shape is seen in what presentation?
cephalic presentation
Triangular shape- formed by the mouth and malar prominence
Straight line is seen in what presentation?
Frank Breech
Straight line- formed by the ischial tuberosities and Anus
Most accurate information that establishes the diagnosis of position and variety in frank breech
Location of the sacrum and its spinous processes
feet may be felt alongside the buttocks
Complete breech
Indian sit
complete breech
If the IE finger is pushed a little bit more beyond the ischial tuberosities/sacrum/anus, then the foot/feet will be felt alongside it
Complete breech
one or both feet are inferior to the buttocks
incomplete breech
feet is the presenting part
incomplete breech
true/false
Vaginal examination of Incomplete breech: foot can be readily be identified as right or left on the basis of the relation to the great toe.
TRUE
Vaginal examination of Incomplete breech: foot can be readily be identified as right or left on the basis of the relation to the great toe.
What you look for during the Ultrasound
- Gross fetal abormalities (hydrocephaly/anencepahly)
- neck flexion/ extension
- fetal weight
- BPD estimation
Factors that aid the determination of the best delivery route for a mother-fetus pair
- fetal characteristics
- pelvic dimensions
- coexistent pregnancy complications
- operator experience
- patient preference
- hospital capabilities
Delivery route when the pelvis has not been tested or it’s been proved that there’s contracted pelvis
CS delivery
Delivery route when the pelvis has been tested from previous deliveries for fetal weight. The present baby lay less
Planned vaginal delivery
Patient has anatomic congenital anomalies present. What is the delivery route?
CS delivery
True/false
Conform to the patient’s decision when a patient would prefer a normal delivery even if it’s breech in presentation
True
Fetus is > 3800 g. What is the delivery route?
CS delivery
*baby is big, and lacerations will occur w/ vaginal delivery
Fetus is <2500 g. What is the delivery route
CS delivery
*baby’s body is smaller compared to the fetal head so the problem of entrapment of the aftercoming head would be present w/ vaginal delivery
preferred delivery route for frank breech
vaginal delivery
preferred delivery route for footling breech
CS delivery
Delivery route in cases of placenta previa or abruptio?
CS delivery
True/false
Any pregnancy complication that compromises the mother or the fetus, then you have to expedite delivery of the breech baby by doing VAGINAL delivery.
False
Any pregnancy complication that compromises the mother or the fetus, then you have to expedite delivery of the breech baby by doing CS section.
True/False
If there is no one skilled to do the maneuvers for vaginal breech deliveries, do not attempt to do vaginal breech deliveries. Go for
a cesarean section.
TRUE
If there is no one skilled to do the maneuvers for vaginal breech deliveries, do not attempt to do vaginal breech deliveries. Go for
a cesarean section.
True/false
preterm deliveries are common in breech babies
True
Preterm deliveries are common in breech babies. Expect respiratory distress and asphyxia. You need to have a good neonatal team for the compromised baby
Increased neonatal mortality and morbidity
Planned vaginal delivery
Causes of death in Planned Vaginal Delivery
- Head entrapment
- Cerebral injury and intracranial hgg.
- cord prolapse
- severe asphyxia
True/false
Planned CS delivery has improved perinatal outcomes compared with planned vaginal delivery
True
True/false
24-32 wks AOG: attempted Vaginal delivery has LOW maternal complication rates and HIGH neonatal mortality rates
True
24-32 wks AOG: attempted Vaginal delivery has LOW maternal complication rates and HIGH neonatal mortality rates
AOG where there is NO improved survival rate on the neonate with CS or vaginal (same poor outcome)
24-29 wks AOG
AOG where Fetal Weight rather than AOG is the most important
32-37 wks AOG
According to SOGC, if the EFW >2500g, what is the route of delivery?
EFW- estimated fetal weight
Vaginal delivery
> 2500g: head is SMALLER than buttocks
<2500 g: head is BIGGER than buttocks; CS delivery because head entrapment and other complications would be higher if with vaginal delivery
Delivery complications
- maternal morbidity
- perinatal morbidity and mortality
TRUE/FALSE
Genital tract lacerations is associated with Vaginal delivery only
FALSE
Genital tract lacerations is associated with BOTH Vaginal and CS delivery
causes of vaginal wall and cervical lacerations
- thinned LUS
- delivery of the aftercoming head through an incompletely dilated cervix
- application of forceps
True/False
With vaginal delivery, extension of an EPISIOTOMY can create deep perineal tears and increase infection rates
True
With vaginal delivery, extension of an episiotomy can create deep perineal tears and increase infection rates
complication of anesthesia used for uterine relaxation during vaginal delivery
Uterine atony
True/False
Maternal death is rare, but rates appear higher in those with planned CS delivery for breech presentation.
TRUE
True/ False
With CS delivery, added to the stretching of the lower uterine segment by forceps or a poorly molded fetal head can extend HYSTERECTOMY incisions laterally and might hit blood vessels
TRUE
With CS delivery, added to the stretching of the lower uterine segment by forceps or a poorly molded fetal head can extend HYSTERECTOMY incisions laterally and might hit blood vessels
Prognosis is worse for fetuses in breech
- increased incidence of preterm delivery
- congenital anomalies
- birth trauma
Common injuries (trauma/compression) during delivery
- fractures (humerus, clavicle and femur)
- upper extremity paralysis (Erb or Duchenne)
- vertebral fracture leading to spinal injury
- testicular injury (if compressed)
- umbilical cord prolapse
- hip dysplasia
4 images technique
- UTZ
- 2 view radiography of abdomen
- CT scan (pelvimetry)
- MRI (pelvimetry)
should be ASSESSED before vaginal delivery to avoid head entrapment
Pelvic dimensions
should be IDENTIFIED before vaginal delivery to avoid head entrapment
- Fetal size
- type of breech
- degree of neck flexion or extension
True/false
the head of a breech presenting fetus does undergo appreciable molding during labor
False
the head of a breech presenting fetus does NOT undergo appreciable molding during labor
True/False
a well-flexed head CANNOT be delivered vaginally
False
Well-flexed head can be delivered vaginally.
Hyperextended head cannot be delivered vaginally
the BEST imaging technique because it is always available, does not entail a big machine, and is cost effective
UTZ
used to confirm a clinically suspected breech presentation and to identify fetal anomalies
UTZ
used to help ensure that CS is not performed under emergency conditions for an anomalous fetus with no chance of survival
UTZ
used to identify orientation of the head
UTZ
used to identify fetuses not suitable for vaginal delivery
UTZ
used to identify head flexion/extension
UTZ
imaging modality used as exclusion criteria for vaginal delivery
UTZ
exclusion criteria for vaginal delivery:
EFW <2500 and >3800
evidence of FGR
BPD >90-100mm
imaging modality to determine head inclination
Two view radiography of abdomen
imaging modality that is accurate and widely available
CT scan
imaging modality that can provide pelvic measurements and configuration at lower doses of radiation than standard radiography
CT scan
imaging modality that suggest specific measurements to permit a planned vaginal delivery
CT scan
although variable, some specific measurements to permit a planned vaginal delivery:
- Inlet anteroposterior diameter ≥10.5 cm
− Inlet transverse diameter ≥12.0 cm
− Midpelvic interspinous distance ≥10.0 cm
Inlet AP diameter to permit planned vaginal delivery
≥10.5 cm
Inlet transverse diameter to permit planned vaginal delivery
≥12.0 cm
Midpelvic interspinous distance to permit planned vaginal delivery
≥10.0 cm
imaging modality for maternal-fetal biometry correlation
CT scan
imaging modality that provides reliable information about pelvic capacity and architecture WITHOUT ionizing radiation
MRI
- pelvic capacity and architecture
- No ionizing radiation
- not always readily available.
Favorable outcome with an breech delivery
- adequate birth canal
- cervix must be fully dilated
Factors favoring CS delivery of a breech fetus
- lack of operator experience in vaginal breech
- patient request for CS; prior CS
- Large fetus >3800-4000g
- apparently healthy and viable preterm fetus
- severe FGR
- prior perinatal death or neonatal birth trauma
- incomplete/ footling breech presentation
- hyperextended head
- pelvic contraction
3 general methods of breech delivery
- spontaneous breech deliver
- partial breech delivery
- total breech delivery
the fetus is expelled entirely spontaneously without any traction or manipulation other than the support of the newborn
Spontaneous breech delivery
the fetus is delivered spontaneously as far as the UMBILICUS, but the remainder of the body is extracted or delivered with operator traction and assisted maneuvers, with or without maternal expulsive efforts
Partial breech delivery
the entire body of the infant is extracted by the obstetrician
Complete breech delivery
done only in CS
Complete breech delivery
controversial in women with breech presentation
Labor induction and augmentation
True/False
Some protocols avoid augmentation. Others recommend it only for hypotonic contractions
TRUE
Some protocols avoid augmentation. Others recommend it ONLY for hypotonic contractions
Labor management
- Rapid assessment of status of the membranes, labor and fetal condition
- close surveillance of FHR and uterine contractions
- recruitment of necessary staff
- IV catheter infusion
- Planning for the route of delivery
necessary staff for labor
- OB skilled in art of breech extraction
- associate to assist with the delivery
- Anesthesia personnel
- staff skilled in newborn resuscitation
used in preparation for anesthesia induction/resuscitation following the possibility of hemorrhage
IV catheter infusion
What will you assess for the planning for the route of delivery?
- cervical dilatation & effacement
- station
- type of breech presentation
True/false
obtain pelvimetry if labor is not too far advances.
True
best indicator of pelvic adequacy
satisfactory progress in labor
What will you assess using the sonography?
- fetal biometry
- head flexion
- fetal anatomy
done during the 1st stage of labor
monitor FHR every 15 mins or continuously
true/false
with ROM, the cord prolapse risk in INCREASED when the fetus is small or NOT in frank breech
TRUE
with ROM, the cord prolapse risk in INCREASED when the fetus is small or NOT in frank breech
Once there’s ROM, do IE and assess if there’s cord
prolapse or none.
- If none: proceed with labor watching.
- If there’s cord prolapse: do not remove your hand in the vagina canal (to prevent further prolapse, and cause hypoxia or asphyxia), while preparing for CS.
should be done following rupture
- vaginal exam
- monitoring of FHR for 15 minutes
usually takes place with the BITROCHANTERIC DIAMETER in one of the oblique pelvic diameters
engagement and descent
In engagement and descent, ANTERIOR hip descents MORE rapidly than the posterior hip. True or False?
True
ANTERIOR hip descents MORE rapidly than the posterior hip
when the resistance of pelvic floor is met, INTERNAL ROTATION to ___ degrees follows.
when the resistance of pelvic floor is met, INTERNAL ROTATION to 45 degrees follows.
-this is to bring the anterior hip toward the pubic arch . allowing the bitrochanteric diameter to occupy the AP diameter of the pelvic outlet
If the posterior extremity is prolapsed, it rotates to the _______ rather than the anterior hip.
If the posterior extremity is prolapsed, it rotates to the SYMPHYSIS PUBIS rather than the anterior hip.
What happens to the perineum and anterior hip after rotation and descent continues.
After rotation, descent continues:
Perineum: distended by the breech
Anterior hip: appears at the vulva
True/False
Anesthesia for breech decomposition and extraction must provide sufficient relaxation to allow intrauterine manipulations
True
may provide sufficient relaxation to allow intrauterine manipulations but increased uterine tone may render the operation difficult
Epidural anesthesia
may be required to relax the uterus as well as to provide analgesia
General anesthesia
used with caution because this will relax the uterus
General anesthesia
Uterus can further relax causing uterine atony which leads to postpartum hgg
General anesthesia
this anesthesia can also go to the baby causing the baby to be in distress
General anesthesia
An episiotomy is made and is an important adjunct to the delivery
Partial breech delivery
True/False
in partial breech delivery, a cardinal rule in successful breech extraction is to employ steady, gentle, downward traction until the lower halves of the scapulas are delivered
True
True/false
in partial breech delivery, as the fetus continues to descend, the legs are sequentially delivered by SPLINTING the medial aspect of each femur with the operator’s fingers positioned parallel to each femur, and by exerting pressure laterally to SWEEP each leg away from the midline.
TRUE
maneuver used in partial breech delivery wherein the obstetrician will hook his index finger into the popliteal fossa of the fetus–> leg will automatically flex–> hook the leg and be delivered out of the vagina
Pinard’s maneuver
maneuver used for the delivery of the arms
Loveset maneuver
maneuver used for the delivery of the aftercoming head
Mauriceau maneuver
In mauriceau maneuver, the index and middle finger of the operator is placed where?
placed on the malar prominence
Forceps applied electively when the Mauriceau maneuver cannot be accomplished easily
Piper forceps or
Laufe-piper forceps
True/False
The blades of the forceps should not be applied to the
aftercoming head until it has been brought into the pelvis by gentle traction, combined with suprapubic pressure, and is engaged.
True
side of the blade of the forceps applied to the aftercoming head
left blade
side of the blade of the forceps applied with the body still elevated
right blade
maneuver used if the back of the fetus fails to rotate anteriorly
Prague maneuver
manuever consisting of two fingers of one hand grasping the shoulders of the back-down fetus from below while the other hand draws the feet up over the maternal abdomen.
modified prague maneuver
incision at 10 o’clock and 2 o’clock to relieve entrapped aftercoming head. Infrequently, an additional incision is required at 6 o’clock.
Duhrssen’s Incision
Do not do the incision on the 3 o’clock or 6 o’clock position
true/false?
True
*cervical branch of the uterine artery is inserted at 3 and 6 o’clock position
Replacement of the fetus higher into the vagina and uterus, followed by CS delivery, to rescue an entrapped breech fetus that cannot be delivered vaginally.
Zavanelli maneuver
very discomforting and distressing maneuver
Zavanelli maneuver
two fingers are inserted along one extremity to the knee, which is then pushed away from the midline after spontaneous flexion
Pinard maneuver
used to deliver a foot into the vagina
Traction
delivery of the fetus in breech position by extending the legs and trunk of the fetus over the pubic symphysis and abdomen of the mother
Bracht maneuver
procedure in which the fetal presentation is altered by physical manipulation, either substituting one pole of a longitudinal presentation for the other or converting an oblique or transverse lie into a longitudinal
Version
used only for the delivery of the 2nd twin
Internal podalic version
for breech fetuses near term, manipulations are performed exclusively through the abdominal wall
External podalic version
accomplished inside the uterine cavity
Internal podalic version
first twin is delivered vaginally. 2nd twin is in cephalic position
Internal podalic version
insertion of a hand into the uterine cavity to turn the fetus manually
Internal podalic version
The operator seizes one or both feet and draws them through the fully dilated cervix while using the other hand to transabdominally push the upper portion of the fetal body in the opposite direction
Internal podalic version
after the internal podalic version operation, it is followed by what extraction
breech extraction
We want a faster delivery. If there is another fetus and the placenta separates, that will compromise the blood supply. That’s why you deliver by breech extraction.
stage of labor where the placenta would separate
3rd stage of labor
indication of external podalic version
If breech presentation is recognized prior to labor in a woman who has reached 36 wks AOG
Contraindications of external podalic version
- vaginal delivery is not an option
- ROM
- uterine malformations
- multifetal gestation
- recent vaginal bleeding
relative contraindication of external podalic version
-prior uterine incision
factors associated with successful version
- multiparity
- abundant amniotic fluid
- unengaged presenting part
- fetal size 2500-3000g
- posterior placenta
- non-obese patient
True/false
when the placenta is placed posteriorly, even if you manipulate the abdomen during the version, it will NOT cause irritability
True
True/false
In an obese patient, the abdomen is floppy and can rotate back to its original breech position after manipulation of version.
True
performed to confirm nonvertex presentation and adequacy of amnionic fluid volume, to rule out obvious fetal anomalies if not done previously, and to identify placental location
UTZ
External monitoring is performed to assess ____
Fetal heart rate reactivity
this test is repeated after version until a normal test result is obtained
Nonstress test
each hand grasps one of the fetal poles, and the buttocks are elevated from the maternal pelvis and displaced laterally
Forward roll
clockwise pressure is exerted against the fetal poles
forward roll
if the forward roll is unsuccessful, this procedure us attempted
backward flip
increase success with version when EPIDURAL analgesia is used
conduction analgesia
True/False
the ACOG recommends conduction analgesia for routinely for external version
False
ACOG: NOT enough evidence to recommend conduction analgesia for routinely for external version
used for uterine relaxation
tocolysis
- betamimetics: terbutaline
- calcium channel blocker: nifedipine
- NO donor: nitroglycerine
Recommended tocolytic agent by the ACOG before version attempt
250g Terbutaline SC
complications of version
- placental abruption
- uterine rupture
- AF embolism
- fetomaternal hgg
- alloimmunization
- preterm labor
- fetal distress
- fetal demise
