Breech Flashcards
What is the definition of breech?
The fetus lies longitudinally with the buttocks in the lower pole of the uterus
What is the bitrochanteric diamter?
femur to femur across - 10cm
What 2 diameters are both 10cm?
head and bitrochanteric
What is the incidence of breech births?
3-4% at term
20% at 28 weeks
What are the variations of Breech?
Complete/flexed
extended/frank
knee
footling
What is complete/flexed breech?
both feet crossed middle
10-15%
risk of PROM and Cord prolapse as feet and buttocks both on cervix
What is extended/frank breech?
45-50% of breeches
feet up by head
What is knee breech?
knee in the birth canal
35-45%
high risk of cord prolapse
what is footling breech?
foot lower than body
more common in preterm
what are the causes of breech babies? 10
prematurity multiple pregnancy abnormal liqour volume firm abdo muscles conracted pelvis hydrocephaly uterine abnormalities placenta praevia, pelvic tumours, fibroids grand multiparity
How do we diagnose breech antenatally? 3
palpation
auscultation
if >36/40
How do we diagnose breech in labour?
VE - breech feels soft and irregular no sutures anus may be felt thick together meconium external genitalia might be felt foot might be felt
What are the managements of breech antenatally ?
maternal position
-knee to chest 15 mins every 2 hours for 5 days
moxibustion (acupuncture)
-33-35/40 may consider - must be trained
What does ecv stand for?
external cephallic version
Define ECV
manipulation of the fetus through the maternal abdomen, to a cephalic presentation
at what gestation is ecv done?
36 for primips
37 for multips
what is the success rate of ecv?
50%- +chance for multips
decreases chance of cs
What risks are there after ecv?
higher chance of fetal distress obstructed labour instrumental - may be op fetomaternal haemorrage cord entanglement amniotic fluid embolism
What makes ecv successful? 5
multiparity frank breech - easier to hold bottom normal or + amniotic fluid relaxed uterus suitable gestational age
What are the contraindications of ECV? 12
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
What position must the mother be in for ecv?
trendelenburg
What is the process of ecv? 10
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
mode of delivery factors - mother
- 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
mode of delivery factors - baby
- 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
Indications for LSCS
4
- hyperextension of the neck on USS (face up)
- EFW >3.8kg or <10th centile
- footling
- antenatal fetal compromise
What can you do for an unplanned vaginal breech birth?
depends on:
- stage of labour
- risk factors
- clinical expertise
When should you not offer a cs?
second stage of labour
What are important to assess in vaginal breech birth?
position
neck + legs
EFW
Can you IOL breech?
No - augmentation can be considered though 2nd to epidural
Care in stages of labour?
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
MEchanism of breech labour 8
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
could i later rest in bed in birmingham
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
What is compaction?
descent with increasing flexion
What is internal rotation of the buttocks?
anterior buttock hits pelvic floor and rotates 1/8 forward - lies underneath pubis
-bitrochanteric diameter in AP diameter
What is lateral flexion of the body?
anterior buttock escapes under pubis, posterior sweeps the perineum
What is restitution of buttocks
?
anterior buttock turns to the mothers left
what is internal rotation of the shoulders?
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
How are the shoulders born?
Anterior shoulder escapes under the pubis and posterior shoulder passes over perineum
How does the head internally rotate?
As baby hangs the weight aids descent and rotation
Complications of a breech vaginal birth
- emcs
- fetal hypoxia - cord prolapse, cord compression, premature separation of placenta (baby pulls on placenta from gravity)
- impacted breech
- cord prolapse
- maternal trauma
Fetal complications of breech vaginal birth
- 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
What manouvre can you use for shoulders stuck?
Lovesetts
What manouvre should you never see?
burns marshall
What is the lovesets manoevre?
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
What manouvre should you use to deliver the head?
Mariceau smellie veit
How do you do mariceau smellie veit?
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
