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Induction and Augmentation of labour > Breech > Flashcards

Breech Flashcards

1
Q

Define Breech…

A

Breech presentation is where the presenting part of the fetus is the buttocks, or feet; Extended (65%), Footling (25%), Flexed (10%)

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2
Q

What are the predisposing factors of a breech presentation?

x12

A 
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
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3
Q

Name the tree types of vaginal breech management..

A

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

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4
Q

Management of labour depends on what 5 things?

A 
Gestation 
Risks associated 
What stage of labour
Mothers consent
clinical expertise of practitioners available
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5
Q

What needs to be prep when delivering a breech?

X7

A

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

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6
Q

Discuss Electronic Fetal Monitoring…

A

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.

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7
Q

Is fetal blood sampling recommended?

A

No

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8
Q

Discuss Augmentation of labour..

A

Augmentation of labour using oxytocin is not recommended.

Amiotomy should be done with caution due to the increased risk of cord prolapse

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9
Q

Once membranes are ruptured what should occur?

A

VE to exclude cord prolapse

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10
Q

Caesereans during second stage….

A

are not routinely offered unless there is a delay.

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11
Q

What could a delay in second stage of labour suggest?

A

fetopelvic disproportion

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12
Q

Who should attend a breech delivery?

A

Senior midwife, obstetrician, paediatrician - anaesthetist and theatre team on standby

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13
Q

Which position should be adopted during delivery?

A

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

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14
Q

At what point should a woman push?

A

When the breech is visible at the perineum active pushing should be encouraged.

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15
Q

What does ECV stand for?

A

External Cephalic Version

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16
Q

What are indications that manoeuvres should be performed?

A

Fetal tone/colour
Fetal destress
Delay: 5min between buttocks and head
3mins between umbilicus and head

17
Q

Are epitomises routine?

A

No they should be used selectively to facilitate birth

18
Q

Where on the babies body should we support it? and why?

A

over the bony prominence of the pelvis to avoid soft tissue damage

19
Q

How should we deliver a breech?

A

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

20
Q

in what position should the buttocks be?

A

sacroanterior

21
Q

What must be avoided and why?

A

umbilical cord as it can cause vascospasm

22
Q

when should the mother be encouraged to push?

A

from rumping until scapulae are visible

23
Q

If the arms are not released which manoeuvre should be performed?

A

Lovsett

24
Q

What are the 5 steps of lovsetts manoeuvre ?

A

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

25
Q

What should happen after the delivery of the arms?

A

support the baby allowing the weight of the baby to encourage flexion.

26
Q

If spontaneous delivery of the head does not follow?

A

apply suprapubic pressure to assist flexion of the head

27
Q

What is the next manoeuvre potentially required?

A

Mauricaeu smellie veit

28
Q

What are the 3 steps of the last manoeuvre consist of?

A

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

29
Q

When would forceps be used?

A

obstetricians may opt for forceps

30
Q

What are the complications during a deliver?

A

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%

31
Q

What are the 9 Fetal risk factors of VBB?

A 
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
32
Q

What is a cord prolapse?

A

the decent of the umbilical cord through the cervix either alongside or past presenting part

33
Q

what are the incidences ?

A

0.1% to 0.6% of all births

1% in breech

34
Q

What are the perinatal mortality rates of a cord prolapse?

A

91 per 1000

35
Q

What are the fetal risk factors?

A

Hypoxic-ischaemic-encephalopathy
cerebral palsy
neonatal death
birth asphyxia

36
Q

What is the management of a cord prolapse?

A

Maternal position
Digital elevation of PP
Reduce contractions
Fill bladder

Induction and Augmentation of labour (4 decks)

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