Breech Flashcards
What is the definition of breech presentation?
The foetus lies longitudinally with the buttocks in the lower segment of the uterus
What is the bitrochanteric diameter?
- 10cm
- Between the greater trochanters of the femurs
- Same diameter as the head
What is one sign of a breech presentation in labour?
Thick meconium in the waters, similar to what its like in the nappy
What are the 5 types of breech presentation?
- Complete/ Flexed (knees to chest)
- Incomplete (1 leg straight, 1 leg bent)
- Frank (Both legs straight)
- Knee
- Footling
What are the uterine risk factors for breech?
- Poly/ Oli
- Firm abdominal muscles
- Uterine abnormalities
- Placenta praevia
What are the foetal risk factors for breech?
- Prematurity
- Multiple pregnancy
- Hydrocephaly/ Anencephaly
- Grand multiparity
How can breech presentation be diagnosed antenatally?
- Palpation
- Auscultation
- If >36/40 = USS to confirm
How can you tell from a VE that the baby is breech?
- PP feels soft and irregular
- No sutures
- Anus may be felt
- Foot may be felt
- Meconium
What is an ECV?
External Cephalic Version - manipulation of the foetus through the maternal abdomen to a cephalic presentation
When is an ECV usually done?
Primip = 36/40 Multip = 37/40
What are the complications of an ECV?
- Foetal distress
- Obstructed labour
- Instrumental delivery
- Placental abruption
- Fetomaternal haemorrhage
- Cord entanglement
When is an ECV most successful?
- Multiparity (softer muscles)
- Frank breech (easier to hold)
- Normal/ increased amniotic fluid
- Relaxed uterus
- Suitable gestation
What are some contraindications of an ECV?
- Abnormal Doppler/ CTG
- Absolute reasons for CS
- Placenta praevia/ abruption
- Multiple pregnancy
- Rhesus isoimmunisation
- Vaginal bleeding within 7 days
- SROM
- IUD
- Severe preeclampsia
What is the procedure for ECV?
- Empty bladder
- CTG
- Trendelenburg position
- ?Tocolysis/ muscle relaxant
- USS
- Obstetrician turns baby (usually forwards)
- CTG
- Observe for distress, ROM, contractions, bleeding
- Kleihauer (anti-D if needed)
What is the Trendelenburg position and why is it used?
- Lie flat with head lowered
- Relieves pressure on cervix
What is internal podalic version?
Feet pulled down on VE - most commonly used to deliver second twin
What is the best mode of delivery for the mother?
- Complications lowest with successful vaginal birth, highest with EMCS
- LSCS = risk of complications in future pregnancies
What is the best mode of delivery for the foetus?
- Planned LSCS
- Reduction of stillbirth, perinatal morbidity and intrapartum risks
What are some indications for LSCS?
- Hyperextension of the neck on USS
- EFW >3.8kg or <10th centile
- Footling
- AN foetal compromise
When should an ELCS be for breech presentation?
39/40
What advice should be given regarding the method of delivery?
- Hospital birth with facilities for immediate LSCS if needed
- IOL not recommended but consider augmentation
- Epidural increases the risk of intervention
What is the role of the midwife in the 1st stage of labour?
- Same as cephalic presentation
- Membranes may rupture early
- Meconium may be present
What is the role of the midwife in the 2nd stage of labour?
- Confirm full dilation
- Consider position
- Inform MDT
- Be prepared with equipment
What position should the mother not be in for a breech vaginal delivery?
Upright, as gravity could cause placental abruption/ early separation
What equipment does the midwife need to prepare?
- Obstetric forceps
- Warm towels
- Lithotomy poles
- Resuscitaire
What are the 6 positions?
- LSA
- RSA
- LSL
- RSL
- LSP
- RSP
Give the relative position of the baby in an RSA mechanism
Lie - longitudinal Attitude - flexion Presentation - breech Position - RSA Denominator - sacrum PP - right buttock
What is the mechanism for a breech birth?
- 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 buttocks?
Anterior buttock hits pelvic floor and rotates forwards, lying under the symphysis pubis - bitrochanteric diameter in AP diameter of pelvis
What is lateral flexion of body?
Anterior buttock escapes under symphysis pubis, posterior buttock sweeps perineum
What is internal rotation of shoulders?
Contractions and weight of baby brings shoulders onto pelvic floor; they enter the pelvis in the right oblique and the anterior shoulder hits the pelvic floor and rotates
What is birth of shoulders?
Anterior shoulder escapes under the symphysis pubis and the posterior shoulder passes over the perineum
What are some maternal complications of breech delivery?
- Emergency LSCS
- Premature placental separation
- Maternal trauma
What are some foetal complications of breech delivery?
- Hypoxia
- Cord prolapse
- Fractures
- Brachial plexus injury
- Trauma to internal organs
- Spinal cord injury
- Intracranial haemorrhage
What are the 3 main causes of foetal hypoxia?
- Cord prolapse
- Cord compression
- Premature placental separation
When is a cord prolapse more common?
In complete or footling breech due to ill-fitting PP
