Breech

Question 1

What is the definition of breech?

Answer 1

The fetus lies longitudinally with the buttocks in the lower pole of the uterus

Question 2

What is the bitrochanteric diamter?

Answer 2

femur to femur across - 10cm

Question 3

What 2 diameters are both 10cm?

Answer 3

head and bitrochanteric

Question 4

What is the incidence of breech births?

Answer 4

3-4% at term

20% at 28 weeks

Question 5

What are the variations of Breech?

Answer 5

Complete/flexed
extended/frank
knee
footling

Question 6

What is complete/flexed breech?

Answer 6

both feet crossed middle
10-15%
risk of PROM and Cord prolapse as feet and buttocks both on cervix

Question 7

What is extended/frank breech?

Answer 7

45-50% of breeches

feet up by head

Question 8

What is knee breech?

Answer 8

knee in the birth canal
35-45%
high risk of cord prolapse

Question 9

what is footling breech?

Answer 9

foot lower than body

more common in preterm

Question 10

what are the causes of breech babies? 10

Answer 10

prematurity 
multiple pregnancy 
abnormal liqour volume 
firm abdo muscles 
conracted pelvis 
hydrocephaly 
uterine abnormalities 
placenta praevia, pelvic tumours, fibroids 
grand multiparity

Question 11

How do we diagnose breech antenatally? 3

Answer 11

palpation
auscultation
if >36/40

Question 12

How do we diagnose breech in labour?

Answer 12

VE -
breech feels soft and irregular
no sutures 
anus may be felt 
thick together meconium 
external genitalia might be felt 
foot might be felt

Question 13

What are the managements of breech antenatally ?

Answer 13

maternal position
-knee to chest 15 mins every 2 hours for 5 days
moxibustion (acupuncture)
-33-35/40 may consider - must be trained

Question 14

What does ecv stand for?

Answer 14

external cephallic version

Question 15

Define ECV

Answer 15

manipulation of the fetus through the maternal abdomen, to a cephalic presentation

Question 16

at what gestation is ecv done?

Answer 16

36 for primips

37 for multips

Question 17

what is the success rate of ecv?

Answer 17

50%- +chance for multips

decreases chance of cs

Question 18

What risks are there after ecv?

Answer 18

higher chance of fetal distress 
obstructed labour 
instrumental - may be op
fetomaternal haemorrage 
cord entanglement 
amniotic fluid embolism

Question 19

What makes ecv successful? 5

Answer 19

multiparity 
frank breech - easier to hold bottom 
normal or + amniotic fluid 
relaxed uterus 
suitable gestational age

Question 20

What are the contraindications of ECV? 12

Answer 20

abnormal dopplers or ctg 
absolute reasons for cs 
placenta praevia 
multiple pregnancies 
rhesus isoimmunisation
pv bleed within 7 days 
SROM 
caution for oligo and hypertension
history of cs 
IUD 
placental abruption
severe pre-eclampsia

Question 21

What position must the mother be in for ecv?

Answer 21

trendelenburg

Question 22

What is the process of ecv? 10

Answer 22

empty bladder 
ctg 
lie in trendelenburg 
? tocolysis - terbutaline, salbutamol
USS throughout 
Obs dr disimpacts the breech 
Apply pressure to both poled rotates into cephalic following its nose 
CTG after
Observe for distress, contractions, bleeding, 
kleihauer and anti d if rh neg

Question 23

mode of delivery factors - mother

Answer 23

• mat complications least with successful vag breech birth, highest with emergency lscs
• lscs + risk of complications in future pregnancies
• small increased risk of stillbirth in subsequent pregnancies with historic lscs

Question 24

mode of delivery factors - baby

Answer 24

• planned lscs - small reduction in perinatal morbidity
• decreased risk - avoidance of stillbirth after 39/40, avoidance of intrapartum risks of vaginal breech birth
• risks of perinatal morbidity 0.5:1000 for lscs, 2:1000 for vaginal breech birth

Question 25

Indications for LSCS

4

Answer 25

• hyperextension of the neck on USS (face up)
• EFW >3.8kg or <10th centile
• footling
• antenatal fetal compromise

Question 26

What can you do for an unplanned vaginal breech birth?

Answer 26

depends on:

• stage of labour
• risk factors
• clinical expertise

Question 27

When should you not offer a cs?

Answer 27

second stage of labour

Question 28

What are important to assess in vaginal breech birth?

Answer 28

position
neck + legs
EFW

Question 29

Can you IOL breech?

Answer 29

No - augmentation can be considered though 2nd to epidural

Question 30

Care in stages of labour?

Answer 30

1st- same labour care as cephalic
-membranes can rupture early

2nd- passive until breech visible - max 2 hours then lscs

• confirm full dilatation -consider position
• be prepared - equipment and staff

Question 31

MEchanism of breech labour 8

Answer 31

compaction 
internal rotation of buttocks 
lateral flexion of body 
restitution of buttocks 
internal rotation of shoulders 
birth of shoulders 
internal rotation of the head 
birth of babys head by flexion

Question 32

could i later rest in bed in birmingham

Answer 32

compaction 
internal rotation of buttocks 
lateral flexion of body 
restitution of buttocks 
internal rotation of shoulders 
birth of shoulders 
internal rotation of head 
birth of head by flexion

Question 33

What is compaction?

Answer 33

descent with increasing flexion

Question 34

What is internal rotation of the buttocks?

Answer 34

anterior buttock hits pelvic floor and rotates 1/8 forward - lies underneath pubis
-bitrochanteric diameter in AP diameter

Question 35

What is lateral flexion of the body?

Answer 35

anterior buttock escapes under pubis, posterior sweeps the perineum

Question 36

What is restitution of buttocks

?

Answer 36

anterior buttock turns to the mothers left

Question 37

what is internal rotation of the shoulders?

Answer 37

uterine contractions and weight of baby bring the shoulders onto the pelvic floor
they enter the pelvis in the right oblique and anterior shoulder hits the pelvic floor and rotates

Question 38

How are the shoulders born?

Answer 38

Anterior shoulder escapes under the pubis and posterior shoulder passes over perineum

Question 39

How does the head internally rotate?

Answer 39

As baby hangs the weight aids descent and rotation

Question 40

Complications of a breech vaginal birth

Answer 40

• emcs
• fetal hypoxia - cord prolapse, cord compression, premature separation of placenta (baby pulls on placenta from gravity)
• impacted breech
• cord prolapse
• maternal trauma

Question 41

Fetal complications of breech vaginal birth

Answer 41

• fractures (humerus, clavicle, femur, dislocated shoulder or hip)
• erbs palsy - damage to brachial plexus from twisting
• trauma to internal organs
• damage to adrenals
• spinal cord injury
• intracranial haemorrhage

Question 42

What manouvre can you use for shoulders stuck?

Answer 42

Lovesetts

Question 43

What manouvre should you never see?

Answer 43

burns marshall

Question 44

What is the lovesets manoevre?

Answer 44

It corrects upward displacement of arms
Rotate baby’s trunk holding the iliac crest so the posterior shoulder comes out below pubis and arm is delivered by flexing the shoulder followed by hooking the elbow and bringing it down
The same procedure is repeated by reverse rotation of 180 degree so the anterior shoulder comes below the pubis

Question 45

What manouvre should you use to deliver the head?

Answer 45

Mariceau smellie veit

Question 46

How do you do mariceau smellie veit?

Answer 46

Lay baby face down with the length of the body on your arm
Use other hand to grasp the baby’s shoulders
With 2 fingers on this hand, flex babys head towards chest while applying downward pressure on the jaw to bring the babys head down until hairline is visible
can kneel and then use momentum of standing to deliver baby’s head