Breech Flashcards
What is the incidence of breech in singletons at term?
3-4%
More common in nullips and in preterm deliveries
What are the contra-indications to vaginal breech delivery?
F - Fetal growth restriction or macrosomia
F - Fetal anomaly incompatible with vaginal breech delivery
A - Any presentation other than frank or complete breech
C - Cord presentation
C - Clinically inadequate maternal pelvis
E - Extension of the fetal head
+ Evidence of antenatal fetal compromise (RCOG GTG)
What is the ideal setting for a planned vaginal breech delivery?
- Can provide CEFM in labour
- Immediate availability of Caesarean section facilities
- Availability of suitably experienced obstetrician to manage the delivery
Is IOL recommended for breech deliveries?
No
Is augmentation (with Synto, for slow progress) recommended for vaginal breech deliveries
Only in the context of reduced contraction frequency in the presence of regional anaesthesia
What position is appropriate for vaginal breech birth?
Semi-recumbent or all-four position
Should take into account the wishes of the woman AND the practitioner
What is the perinatal mortality of planned vaginal breech delivery compared to planned CS for breech?
2/1000 vs 0.5/1000
(1/1000 for planned Cephalic birth)
Reasons for difference
- Avoidance of stillbirth after 39/40
- Avoidance of intrapartum risks
- Avoidance of risks of vaginal breech birth
What is moxibustion?
A traditional Chinese medicine therapy using Mona (made from dried mugwort)
Has been used from 32/40 to promote spontaneous version from breech to Cephalic presentation
What gestation should ECVs occur?
From 37/40
From 36/40 for nullips (but not multiple, as spontaneous version is more common)
Gestation at term does not appear to affect success rates
In women having ECVs, what is the rate of serious adverse outcomes?
1: 200 will require EmCS for serious adverse outcome such as
- placental abruption
- cord prolapse
- acute fetal compromise
In women having ECVs, what is the rate of minor complications?
4.3%
Transient CTG abnormalities, rupture of membranes, small APH
What is the success rate of ECV in nullips?
40%
What is the success rate of ECV in multips?
60%
What is the rate of spontaneous version to breech after successful ECV?
3%
What is the rate of spontaneous version from breech to Cephalic at term in primips after 36/40?
8%
What factors increase the success rate of ECV?
P - Palpable fetal head U - Use of tocolytics M -Multiparity P - Posterior placenta M - Maternal weight <65kg A - AFI > 10 N - Non-engagement of the breech C - Complete breech position
Which is the best tocolytic for ECV? Name, class and dose
Betamimetics
Terbutaline
250mcg subcutaneous
What are the contra-indications for terbutaline?
Significant cardiac disease
Hypertension
Medicated with b-blockers
What are the side effects of terbutaline?
Maternal palpitations Tachycardia Flushing Tremor Occasional nausea
Should regional anaesthesia be used for ECV?
Not routinely
But can be used for women unable to tolerate the procedure
Can ECV be used in Unstable Lie?
What are the risks of it?
Yes, in the course of stabilising IOL, only if IOL if indicated
Risks
Cord prolapse, transverse lie in labour, abnormal CTG
What are the absolute contra-indications to ECV?
A - Anterpartum haemorrhage within the last 7 days
M - Major uterine anomaly
W - Where caesarean delivery is required (for another indication)
A - Abnormal CTG
R - Ruptured membranes
M - Multiple pregnancy
Tactile stimulation of the breech fetus may result in….
Reflex extension of the arms or head
Should be minimised
What are the indications for intervention in a vaginal breech birth
(When should you not be Hands off)
Poor tone, extended arms or an extended neck
More than 5 minutes from delivery of buttocks to head
More than 3 minutes from delivery of umbilicus to head
