Breech

Question 1

What are the 3 types of breech?

Answer 1

Frank (hips flexed, knees flexed) 50-70%
Complete (hips flexed, knees extended) 5-10%
Footling/Incomplete 10-30%

Question 2

What are five risk factors for breech

Answer 2

1. prematurity (24% at 28 weeks)
2. oligohydramnios
3. uterine anomalies (septum, bicornuate, fibroids)
4. previous breech
5. low lying placenta/previa
6. fetal anomalies (anencephaly or hydrocephaly)
7. idiopathic

Question 3

Five pre-requisites to do an ECV

Answer 3

1. no contra-indication to vaginal delivery
2. > 36 weeks
3. normal NST/BPP prior
4. ultrasound available
5. ability to perform urgent C/S if complication
6. singleton
7. adequate amniotic fluid
8. position of fetus known prior to procedure

Question 4

Contraindications to ECV (5 absolute and 5 relative)

Answer 4

Absolute:
1. multiples
2. contraindication to vaginal delivery
3. ruptured membranes
4. major fetal anomalies
5. APH
Relative:
1. oligo
2. hyper-extended head
3. maternal morbid obesity
4. 2 or more previous C/S
5. active labour
6. uterine malformation
7. fetal anomaly

Question 5

5 risks of an ECV:

Answer 5

1. placental abruption (0.4-1%)
2. ruptured membranes/cord prolapse
3. alloimmunization/fetomaternal hemorrhage (1-5%)
4. labour
5. FHR abnormality

Question 6

3 “non-medical” ways to encourage turning of breech baby

Answer 6

1. moxibustion (burning Moxa near pressure point on 5th toe)
2. fetal vitro-acoustic stimulation (insufficient trials)
3. knee-chest position (shown not to be effective in Cochrane review

Question 7

Term Breech Trial:
What did it show?
What were the limitations?

Answer 7

multicentre RCT randomized to elective C/S vs trial of labour: stopped early as sig inc in perinatal/neonatal morbidity in labour group (1.6 vs 5%) and perinatal death (0.3 vs 1.3%)
Limitations: 1) inadequate case selection and intrapartum mgmt (no requirement for U/S, 7 of 16 perinatal deaths associated with IUGR fetus)
2) centres with varying levels of obstetrical skill used in trial (no requirement that experienced provider be present)
3) short term morbidity used as surrogate for long-term neurological outcome

Question 8

What was the PREMODA study?

Answer 8

Prospective observational study (4x larger than Term Breech Trial) found no sig difference in same outcomes as TBT comparing TOL to CS
only difference was 5 minute APGAR score <4

Question 9

Name 5 contraindications to vaginal breech delivery

Answer 9

1. cord presentation
2. any presentation other than frank/complete breech with flexed or neutral head
3. growth restriction or macrosomia (<2500 or >4000)
4. clinically inadequate pelvis
5. fetal anomalies incompatible with vaginal delivery

Question 10

Name 5 risks association with vaginal breech delivery

Answer 10

1. low one minute apgar
2. head entrapment in incompletely dilated cervix (0-8.5% Duhrrsen maneuver.. Zavenelli as last resort)
3. nuchal arms –> brachial plexus injury
4. cervical spine injury from hyperextended head
5. cord prolapse (7.5% of all breech deliveries but varies with type of breech)

Question 11

Technique for vag breech delivery:

Answer 11

1. ensure effective progress through labour (1cm/hr when active, passive descent ok, if delivery not imminent after 60min active pushing then CS)
2. adequate analgesia
3. spontaneous descent and expulsion to umbilicus with maternal pushing only (DO NOT PULL ON BREECH)
4. rotate to sacrum anterior
5. do not extract legs until popliteal fossa visible (Pinard)
6. rotate body to facilitate delivery of arms by sweeping humerus across chest (Loveset), rotate other arm anterior and repeat
7. keep body horizontal
8. Mauriceu-Smellie-Veit to deliver head in flexion
9. can use Piper’s forceps if needed