Breech presentation and delivery

Question 1

what are possible risk factors for a breech (12)

Answer 1

1. Uterine
   - congenital abnormalities- unicornuate uterus
   - uterine tumors- leiomyoma
   - pelvic tumors compressing the uterus
2. Fetal
   - Motor or neurological abnormalities e.g spina bifida
   - Hydrocephalus
   - Short cord
3. Pregnancy
   - Placenta previa
   - Multiple pregnancy
   - Polyhydramnios
   - Oligohydramnios
   - Previous breech presentation
   - Advanced extrauterine pregnancy

Question 2

what makes breech presentations vary

Answer 2

attitude (flexion or extension) of the lower limbs

Question 3

what are the types of breech (2)

Answer 3

1. complete breech presentation (both hips and knees are flexed)
2. incomplete breech presentation
   - frank breech (both hips are flexed but the knees are extended)
   - footling breech (one or both hips are extended with the knees extended)

Question 4

what ECV

Answer 4

External manual pressure is used to lift the presenting part out of the pelvis and then turning the fetus around to the cephalic presentation.

Question 5

how do you diagnose a breech from the history (2)

Answer 5

1. Previous breech presentation
2. Fetal movements low in the abdomen

Question 6

how do you diagnose a breech from physical exam (4)

Answer 6

Leopalds maneuvers
1. fundal grip
- Fetal head palpable in the uterine fundus
2. lateral grip
- To confirm a longitudinal lie
3. pawlik grip and the deep pelvic grip
- Unable to define a head in the lower pole of the uterus
Soft conical and poorly defined presenting part felt

4. Fetal heart rate is usually heard above the umbilicus in a term breech presentation

Question 7

how do you distinguish a breech presentation from a face presentation

Answer 7

1. Breech:
   fetal anus is found directly between the ischial tuberosities
2. Face presentation:
   - Nose can be felt
   - Mouth not directly between the cheek bones
   - Examiners finger may induce a suck reflex if inserted in fetal mouth

Question 8

how do you confirm a breech

Answer 8

USS at 37 weeks as well as to rule out obvious abnormalities

Question 9

how is ECV made easier

Answer 9

using a tocolytic like salbutamol 250mcg IV before procedure

Question 10

what should be performed before and after the ECV

Answer 10

CTG

Question 11

how do you confirm successful ECV

Answer 11

portable ultrasound machine

Question 12

what are absolute contraindications for ECV (6)

Answer 12

Absolute:
1. Rh negative status
2. uterine scar
3. abnormal placentation
4. Fetal compromise
relative:
5. oligohydramnios
6. multiple gestation

Question 13

what are risks of ECV (6)

Answer 13

1. Placental abruption
2. Rupture of membranes
3. Cord accidents
4. Uterine rupture
5. Fetal distress
6. Failure of ECV

Question 14

what situations would you recommend a c/s in a breech presentation (7)

Answer 14

1. Large baby with EFW ≥ 3.5 kg
2. BPD > 9.5 cm
3. Footling breech
4. Extended head
5. Clinically small pelvis
6. Nulliparous (primigravida)
7. Concomitant soft indications for caesarean delivery (i.e. preeclampsia)

Question 15

what are pre requisites to perform a vaginal breech delivery (5)

Answer 15

1. Extended or flexed breech (Complete or frank breech)
2. No evidence of feto-pelvic disproportion (pelvis clinically adequate and estimated fetal weight of ≤3500g)
3. No evidence of hyperextension of the fetal head and fetal abnormalities should have been searched for
4. Multiparous
5. Breech deeply engaged

Question 16

what are maternal complications of breech delivery (5)

Answer 16

1. prolonged labor with maternal distress
2. perineal lacerations
3. PPH due to prolonged labor and lacerations
4. puerperal sepsis
5. obstructed labor- impacted breech with extended legs

Question 17

what are fetal complications of breech delivery (3)

Answer 17

Fetal mortality due to:
- intracranial hemorrhage
- fracture dislocation of the cervical spines
- asphyxia