Breech Flashcards
Green
What is breech presentation?
Presentation of the buttocks of the foetus in the lower segment of the uterus/pelvis
What percentage of babies are breech at
a) 20w?
b) 28w?
c) term?
a) 40%
b) 20%
c) 3%
What are the causes/associations?
Idiopathic (most common)
Uterine abnormalities (e.g. bicornuate uterus, fibroids)
Prematurity
Placenta praevia
Oligohydramnios
Foetal abnormalities e.g. hydrocephalus
Conditions preventing movement (twin pregnancies, pelvic tumours, praevia, pelvic abnormalities) common
What form of breech is most common?
Extended breech (70%) - flexed hips, extended knees; presenting component buttocks
What other forms of breech are there?
Fixed breech (15%) - hips and knees flexed, presenting component buttocks, external genitalia and feet Footling breech (15%) - presenting component feet
What complication is associated with footling breech?
Cord prolapse (5-20%)
How does breech present antenatally?
Pain under ribs
Lie longitudinal on palpation, no head in pelvis
Head ballotable in fundus
How can breech be definitively diagnosed?
USS
vaginal exam if woman labouring
What percentage of breech is undiagnosed in labour?
30%
What are the complications associated with breech?
Perinatal and long-term morbidity and mortality increased
Foetal abnormalities increased
Slightly increased risk neurological handicap
Hazards in labour (hypoxia, birth trauma)
How can it be managed?
External cephalic version (ECV)
Managing mode of delivery
What is ECV?
Turning baby to cephalic by external moving through a typically forward somersault. Should only be performed if a vaginal delivery is planned after 36-37w
What is the success rate of ECV?
Primips - 40%
Multips - 60%
What are the contraindications of ECV?
Placenta praevia
Multiple pregnancy (except delivery of second twin)
APH in last 7d
Ruptured membranes
FGR
Abnormal CTG
Maternal uterine abnormality, uterine scars
Foetal abnormality
Pre-eclampsia, or HNT (inc risk of abruption)
What should be done in addition to ECV?
Monitor CTG
Give anti-D to Rh -ve mothers
How many ECVs are converted to emergency caesarean sections?
1 in 200
How many successful ECVs will return to breech?
3%
What may be given to the mother to make ECV easier?
Uterine relaxant (tocolytic)
What factors indicate a less successful ECV?
Nulliparity Caucasian Engaged breech High uterine tone/head not easily palpable Obesity Low liquor volume
Does the mode of delivery affect morbidity and mortality?
Neonatal morbidity and mortality is increased regardless of mode due to breech position (breech babies more likely to be preterm/congenital abnormalities)
Which mode of delivery is better for baby?
LSCS has better outcomes (dec. risk of NICU admission?
What mode of delivery should be performed in the case of twins?
1st twin breech - LSCS
2nd twin breech - vaginal
What are the contraindications to vaginal breech delivery?
Inexperienced clinician Footling or kneeling breech High (>3800g) or low (<2000g) foetal weight Previous LSCS Hyperextended foetal neck
What approach should the clinician take in a vaginal breech delivery?
Hands off technique; don’t touch until scapulae visible
Attempt to keep spine anterior (Lovset’s procedure - with thumb on sacrum rotate baby 180 degrees clockwise, then counterclockwise with gentle downward traction)
Hook arm at elbow
Deliver head with Mauriceau-Smellie-Veit manoeuvre (two fingers of right hand on maxilla, two fingers of left on occiput to flex head)
