Breech Presentation Flashcards
What is breech presentation?
When the fetus is ‘bottom down’
What are the three types of breech presentation?
- Frank breech
- Flexed breech
- Knee or footling presentation
What is frank breech presentation?
The legs lie extended along the fetal trunk and are flexed at the hips and knees
What presents at the pelvic inlet in frank breech presentation?
The buttocks
What is flexed breech presentation?
The legs are flexed at the hips and knees with the fetus sitting on its legs
What presents at the pelvic inlet in flexed breech presentation?
Both feet
What is footling or knee presentation?
One or both of the lower limbs of the fetus are flexed and breech of the baby is above the maternal pelvis so that part of the lower limb (usually the feet) descends through the cervix
What is the incidence of breech presentation dependent upon?
Gestational age at the time of onset of labour
What is the incidence of breech presentation at 32 weeks?
16%
What is the incidence of breech presentation at 36 weeks?
7%
What is the incidence of breech presentation at term?
3-5%
What does the decline in incidence of breech presentation with increasing gestational age illustrate?
The fetus normally corrects its own position and any artificial attempts before 37 weeks are generally unnecessary
What are the risk factors for breech presentation?
- Lax uterus
- Uterine abnormalities or tumour
- Placenta praevia
- Abnormal pelvic brim
- Maternal smoking
- Maternal diabetes
- Fetal malformation
- Multiple pregnancy
- Oligo/Polyhadramnios
- Low birth weight
- Previous breech presentation
What is a lax uterus usually associated with?
High maternal parity
Is the diagnosis of breech presentation clinically significant before 35 weeks?
No
What are the signs and symptoms suggestive of breech presentation after 35 weeks?
- Subcostal tenderness
- Ballotable head in the fundal area
- Softer, irregular mass in pelvis
- Fetal heartbeat loudest above umbilicus
- On VE in labour, the sacrum, anus or foot can be palpated
What test can confirm breech presentation?
USS
What should happen to any suspected breech presentation after 36 weeks?
Scan and specialist opinion
Why is breech presentation significant?
It carries specific hazards to the infant
Which infants are particularly at risk in breech presentation?
- Preterm
- Macrosomia
What are the risks to the infant of being born breech presentation?
- Increased risk of cord compression and cord prolapse
- Entrapment of head behind cervix
- Intracranial haemorrhage
- Trauma to viscera during delivery
Why is there an increased risk of cord compression or prolapse in breech presentation?
Due to the irregular nature of the presenting part
What type of breech presentation is particularly prone to cord compression or prolapse?
Footling
What infants are particularly at risk of entrapment of head behind the cervix in breech presentation?
Preterm infants
Why are preterm infants particularly at risk of head entrapment behind the cervix in breech presentation?
The bitrochanteric diameter of the breech is significantly smaller than the biparietal diameter of the head meaning trunk can descend through undilated cervix
What can happen in delayed delivery due to entrapment of head behind the cervix in breech presentation?
Child may be asphyxiated and die or have brain damage
Why can intracranial haemorrhage occur in breech presentation?
Because the fetal skull does not have time to mould during delivery
How can trauma to the viscera occur during breech presentation delivery?
Obstetrician handles fetal abdomen leading to rupture of the spleen or gut
What is it best to do due to the risks of breech vaginal delivery?
Avoid the scenario happening
What is the first way to avoid breech delivery?
Performing external cephalic version (ECV)
When is ECV indicated?
When there is breech presentation after 36 weeks
What are the contraindications to ECV?
- History of antepartum haemorrhage
- Placenta praevia
- CTG abnormal
- Previous uterine scar
- Pregnancy is multiple
When is it pointless performing ECV?
When the baby will be delivered by caesarean section anyway
How is ECV performed?
- Rest mother supine with upper body tilted back
- Confirm placental position on USS
- Check fetal heart rate
- Tocolytic agent given to relax uterus
- Breech is disimpacted from pelvic brim and shifted to lower abdomen
- Fetus is gently rotated with head flexed
Give two examples of tocolytic agents used in ECV?
- Oral nifedipine
- IM terbutaline
What should be monitored throughout the procedure?
Fetal heart rate
What should be done if there is fetal bradycardia during ECV?
Return to normal position if not past the hallway point
What are the risks of ECV?
- Cord entanglement
- Placental abruption
- Rupture of membranes
- Persistent fetal bradycardia
What % of cases of ECV have fetal bradycardia occur?
~1%
What may fetal bradycardia due to ECV necessitate?
Emergency c-section
In what % of cases is ECV successful?
Up to 50% at best
What should be taken into account when assessing suitability for ECV?
- Size of the fetus
- Size and shape of maternal pelvis
How does first stage of labour differ in vaginal breech delivery?
Shouldn’t differ at all
What is the preferred option for pain relief in breech vaginal delivery?
Epidural
When should a woman go to hospital who is due to have a breech vaginal delivery?
As soon as contractions or ROM occurs
What should be excluded on presentation to hospital in breech labour?
Cord presentation or prolapse via vaginal examination
When the cervix is fully dilated and presenting part is low in the pelvis in breech delivery what advice is given to the mother?
Bear down with contractions until buttocks and anus come into view
What should be considered in breech delivery to avoid soft tissue resistance?
Episiotomy under local anaesthetic or epidural
What happens once the fetal buttocks come into view in breech delivery?
The rest of the baby is delivered but I’m not gonna explain how because its a bit long tbh
What can cause complications to occur during breech vaginal delivery?
- Poor technique
- Mother pushing before full dilation
When is c-section indicated for breech presentation?
- Estimated birth weight <1.5kg or >4kg
- Footling presentation
- When head is deflexed on ultrasound
- No obstetrician available experienced in breech vaginal delivery
- Additional obstetric complications*
What additional obstetric complications are indications for c-section for breech delivery?
- Severe pre-eclampsia
- Placental abruption
- Placenta praevia
- Previous c-section
What form of c-section is usually used for breech presentation?
Lower segment C-section
What type of c-section can be used for breech presentation in a preterm infant?
Midline incision
