Breech Flashcards
Define Breech…
Breech presentation is where the presenting part of the fetus is the buttocks, or feet; Extended (65%), Footling (25%), Flexed (10%)
What are the predisposing factors of a breech presentation?
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Previous Breech High parity Multiple pregnancy Preterm labour Polyhydramnios / oligohydramnios Pelvic tumours or fibroid Hydrocephaly/anencephaly Placenta previa Uterine abnormalies Fetal head or neck tumours Fetal neuromuscular disorder
Name the tree types of vaginal breech management..
Spontaneous- fetus allowed to descend with no assistance or manipulation
Assisted- fetus allowed to descend using “hands off approach” however recognised manoeuvres are used when required
Extracted- often only used in the case of a second non-cephalic twin, the feet are pulled from the uterine cavity through the vagina where recognised manoeuvres are continued
Management of labour depends on what 5 things?
Gestation Risks associated What stage of labour Mothers consent clinical expertise of practitioners available
What needs to be prep when delivering a breech?
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Staff informed: senior midwife, obstetrician, paediatrician, - anaesthetist, and theatre team on stand by
Confirm mode of delivery with woman
Discuss analgesia
Intravenous access- FBC, G&S
Explain birth techniques
Explain reason for attendants at birth
Prep room- prerequisites for assisted delivery- forceps, operative vaginal delivery pack, lithotomy support, neonatal resuscitation equip
Discuss Electronic Fetal Monitoring…
EFM is recommended throughout labour until delivery as it is likely to improve neonatal outcomes
A pathological trace in the first stage of labour a caesarean is recommended unless the buttocks is visible or progress is rapid.
Is fetal blood sampling recommended?
No
Discuss Augmentation of labour..
Augmentation of labour using oxytocin is not recommended.
Amiotomy should be done with caution due to the increased risk of cord prolapse
Once membranes are ruptured what should occur?
VE to exclude cord prolapse
Caesereans during second stage….
are not routinely offered unless there is a delay.
What could a delay in second stage of labour suggest?
fetopelvic disproportion
Who should attend a breech delivery?
Senior midwife, obstetrician, paediatrician - anaesthetist and theatre team on standby
Which position should be adopted during delivery?
Limited evidence though MRI pelvimetry studies suggest upright active creates more room in the pelvis.
The woman’s choice though all fours, semi-recumbent, and forwarding facing squat are recommended by RCOG
If manoeuvres are the woman should return to semi-recumbent
At what point should a woman push?
When the breech is visible at the perineum active pushing should be encouraged.
What does ECV stand for?
External Cephalic Version
What are indications that manoeuvres should be performed?
Fetal tone/colour
Fetal destress
Delay: 5min between buttocks and head
3mins between umbilicus and head
Are epitomises routine?
No they should be used selectively to facilitate birth
Where on the babies body should we support it? and why?
over the bony prominence of the pelvis to avoid soft tissue damage
How should we deliver a breech?
using a hands off approach, spontaneous delivery of the limbs and trunk is preferred though pressure to the popliteal fossae (spell) may be needed to release the leg
in what position should the buttocks be?
sacroanterior
What must be avoided and why?
umbilical cord as it can cause vascospasm
when should the mother be encouraged to push?
from rumping until scapulae are visible
If the arms are not released which manoeuvre should be performed?
Lovsett
What are the 5 steps of lovsetts manoeuvre ?
1) hold the baby over the bony prominence of the pelvic girdle
2) Rotate baby so one arm is anterior
3) Using index finger place over the infants shoulder and follow the arm to the antecubital (spell)fossa the arm should be flexed for delivery
4) following the release of the arm rota 180 degrees so the second arm is now anterior
5) use the same technique to release arm
What should happen after the delivery of the arms?
support the baby allowing the weight of the baby to encourage flexion.
If spontaneous delivery of the head does not follow?
apply suprapubic pressure to assist flexion of the head
What is the next manoeuvre potentially required?
Mauricaeu smellie veit
What are the 3 steps of the last manoeuvre consist of?
1) support baby’s body with the flexor surface of the practioners forearm
2) the first and third of the practitioners hand should be placed on the cheekbones
3) with the other hand apply pressure to theocciput with the middle finger and place the other fingers simultaneously on the shoulders to promote flexion of the fetal head (chin on chest) to reduce diameter
When would forceps be used?
obstetricians may opt for forceps
What are the complications during a deliver?
Head entrapment - occurs in 14% of VBB
Nuchal arms- when both arms become extended and trapped behinf fetal head - 5% of VBB
Cord prolapse- especially footling 10-25%
What are the 9 Fetal risk factors of VBB?
intrapartum death Intracranial haemorrhage hypoxia-ischaemia- encephalopathy brachial plexus injury ruptured liver, kidney, spleen dislocated neck, shoulder,hip fractured clavicle, humerus, femur cord prolapse cerebellar injury
What is a cord prolapse?
the decent of the umbilical cord through the cervix either alongside or past presenting part
what are the incidences ?
0.1% to 0.6% of all births
1% in breech
What are the perinatal mortality rates of a cord prolapse?
91 per 1000
What are the fetal risk factors?
Hypoxic-ischaemic-encephalopathy
cerebral palsy
neonatal death
birth asphyxia
What is the management of a cord prolapse?
Maternal position
Digital elevation of PP
Reduce contractions
Fill bladder
