Breech presentation and labour Flashcards
what is breech position
fetus is in longitudinal lie and its’ buttock is the lower most part. (upside down)
how are breech position babys delivered
C-section
cause of breech posish
exogenous: -insufficient intrauterine space for foetal movements
endogenous: -foetal inability to adequately move
rf for breech presentation
Maternal
- Uterine anomalies (bicornuate, septate)
- Space occupying lesions (e.g fibroids)
- Ovarian tumours
Pregnancy
- Multiparity (in particular grand multiparas) pelvis
- Oligohydramnios/ Polyhydraminos
- Short umbilical cord
- Placenta previa
Fetal
- Prematurity
- Fetal anomalies (e.g neurological, hydrocephalus, anenecephaly)
- Fetal death
- Extended legs; because they splint the trunk, and so i_nterfere with spontaneous cephalic version_
positions prevalant in the 3 trimesters
1st trimester = equal chances of cephalic and breech presentation
2nd trimester = increased incidence of cephalic presentation and decreased breech presentation
3rd trimester = stable incidence of cephalic and breech presentation
maternal factors increasing risk of breech position
-uterine abnormalities -Space occupying lesions (e.g fibroids) -Contractures -Multiparity (in particular grand multiparas) pelvis
what is grand multiparitiy
≥5 live births and stillbirths ≥20 weeks of gestation,
factors relating to pregnancy that increase the risk of breecch presentation
-prematurity -short umbilical -oligohydromnious -placenta previa
fetal factors causing breech position
-hydro/ anencehpalus - fetal death - Extended legs;
how do extended legs increase risk of breech
they splint the trunk, and so interfere with spontaneous cephalic version
methods to determine breech position
abdominal exam :
- Leopold Maneuver(1st) – Fetal head occupying the fundus of the uterus
- Leopold Maneuver ( 3rd & 4th) – breech occupying the lower pole of the uterus
vaginal exam
- Complete breech
- Frank breech
- Footling / Knee presentation
US: confirm dg
which type of abdominal exam is done to determine breech position
a. Leopold Maneuver(1st type) – Fetal head occupying the fundus of the uterus
b. Leopold Maneuver ( 3; 4th types) – breech occupying the lower pole of the uterus
different breech presentations
a. Complete/ extended breech(10%): flexed hips and knees fet above fetal buttocks
b. incomplete/ Frank breech (65%): flexed hips knees extend over anterior body
* palpable: ischial tuberosity, genitals and anus - causes muconiam stain on fingers
c. Footling / Knee presentation(25%): one/ both hips and knees extended w/ one or both feet are presented
- single footling: one foot is presented
- double footling: both feet are presented
*
list the (8) types of breech positions in the uterus
based on where the fetal sacrum is
left sacro - anterior= MC ; right sacro - anterior
left sacro-posterior ; right sacro-posterior
left sacro-transverse; right sacro-transverse
direct sacro-anterior; direct sacro-posterior
whate are the indications for a CS in breech presentation (6)
- Baby weight >3.5kg
- Hyperextensions of the head
- Suspected pelvic contraction
- Obstetric or medical complications (htn, thydoid, db)
- Any degree of contraction or unfavorable shape restriction
- Previous perinatal death or children suffering from birth trauma
indications for vaginal delivery in breech presentation (8)
- Spontaneous onset of labour
- any breech except FOOTLING
- causes prolapse of umbilical cord
- Gestational age > 36 weeks
- Estimated foetal weight b/n 2.5-3.5 kg
- Foetal head must be flexed not extended!
- Adequate maternal pelvis on x-ray or ct pelvimetry
- No other obstetric complications
types of vaginal delivery in breech position
spontaneous:
- rare case usually in preterm delivery
- no infant manipulation required only support the infant in delivery
partial breech extraction
- spontaneous descent of the fetus until the umbilicus reaches vaginal introuitus after this the fetus is extracted
total breech extraction
- entire body is extracted
- indications
- fetal distress
- other maneuvers innefective
- CS impossible
- twins
- prolapsed cord
- prolonged 2nd stage of labour
what is the mech of a breech labor
loveset’s manoeuvre
1st the breach (legs and buttocks) is delivered
- rotate trunk and pull down at the iliac crest
- continue till the posterior shoulder is at the pubic symph
2nd the shoulders and arm
- flex the shoulder and hook and bend the elbow
- pull the forarm in a snake like movement
- reverse rotation of the body at 180 degrees and do the same for the other shoulder and arm
- anterior shoulder should pass pubic symph
3rd head is last when the hairline presents
- engage the head
- decent: head enters the pelvis in the anterior quad
- flexion
- internal rotation
- head delivery:
what is the most common type of vaginal delivery in breech
assited breech delivery
what is assited breech delivery
Spontaneously delivery up to umbilicus THEN manoeuvres are initiated to assist in the delivery of the remainder
examples
- Burns Marshall method
- Mauriceau-Smellie-veit maneuver
- Prague maneuver
- Pinard maneuver
- Piper forceps
describe the Burns Marshall method for delivery of the head
- deliver shoulder and both arms -,
- baby left to hang unsupported from mums vulva by its weight -
- downward, backward , supra pubic pressure to promote head flexion
- right hand grasps ankles w/ finger between them
- trunk swung upward and forward til mouth is away from vulva
- Depress the trunk to deliver the rest of head
- left hand guards perinuem
Mauriceau-Smellie-veit maneuver
- suprapubic pressure by 1 obstetrician on the mother/uterus
- another obstetrician inserts left hand in vagina to palpate the fetal maxilla
- using the index and middle finger and gently pressing on the maxilla the doc brings the neck to a moderate flexion.
- The left hand’s palm rest against the fetus’ chest and right grabs either shoulder of the fetus
- and pull to cause combined neck flexion and traction on the fetus toward the hip/pelvis
- suprapubic pressure on the mother/uterus allows for delivery of the head of a breech infant,
*
Prague manoeuvre
used when fetal occiput is posterior
- delivers the shoulders with one hand, while making pressure above the symphysis pubis with the other hand.
Piper forceps
Application of piper forceps assist delivery
- The cervix must be fully dilated and retracted and the membranes ruptured.
- The urinary bladder should be empty, perhaps with the use of catheter.
complications of vaginal beech
- Cord prolapse 2. Birth trauma 3. Asphyxia from cord prolapse
what is Extracephalic version presenatation
procedure used to turn the fetus from a breech position to cephalic before labour begins allowing vaginal delivery.
when is Extracephalic version presenatation done
37 wks or during labour before amniotic sac rupture
what dg are done alongside Extracephalic version
fetal US for
- cocnfirming fetal posish & loc of placenta
- confirms amniotic fluid vol
fetal heart rate monitoring during and after the version. - stop the procedure of abnormal values
when is HR monitoring don in extracephalic version
during and after
describe the procedure of Extracephalic version
- tocolytic to relax uterus + prevent uterine contractions - Terbutaline
- Whilst the uterus is relaxed doctor turns the foetus.
- Amount of discomfort is subjective to the pt. factors such as the pressure of the doctor and the sensitivity
risks of Extracephalic version
- Placental abruptions( manual seperation of placenta from wall)
- Premature membrane ruptures
- Cord accident (compression)
- Transplacental hg
- Fetal bradycardia ( manual compression- vagal?/ cord compress)
ECV relative CI
relative reps
- rhesus autoimmune rxn
- elderly primigravida
- oligo/polyhydramnios
ECV absolute CI
- previous uterins scar
- placenta praevia
- pre eclampsia
- mx pregnancy
CI of external cephalic version
relative: rhesus autoimmune rxn elderly primigravida oligo/polyhydramnios
absolute: previous uterinescar; placenta praevia; pre eclampsia; mx pregnancy
