Breech Theory Flashcards
Breech presentation definition
Where the presenting part of the fetus is the buttock or feet
(Prompt 2017)
Incidence of breech presentation
Common before 37/40, with a suggested incidence of 15% at 29-32 weeks, reducing to 3-4%. By 34/40 the majority of breech babies will turn to a vertex
(Mayes 2012)
Types of breech presentation
- Flexed/complete - the fetus sits with the thighs and knees flexed with the feet close to the buttock (10-15%)
- Extended/frank - the fetal thighs are flexed, the legs are extended at the knees and lie alongside the trunk, with the feet near the fetal head (45-50%)
- Footling presentation - one or both feet present below the fetal buttock, with the hips and knees extended (more common in preterm)
- Knee presentation - one or both knees present below the fetal buttock, with one or both hips extended and the knees flexed (35-45%)
(Mayes 2012)
Maternal causes of breech presentation
Primigravidae - firm abdominal and uterine muscle may prevent flexion of the fetal legs, especially when they are already extended
Uterine abnormalities - bicornuate uterus may restrict fetal movement and a previous breech birth may be strongly associated with a uterine abnormality
Uterine fibroid - can interfere with fetal activity or when situated in the lower uterine segment can prevent the fetal head from entering the lower pole of the uterus
Contracted pelvis - fetal head unable to enter the pelvic brim
Maternal alcohol or drug use - may lead to fetal hypotonia in which the lack of movement, reduced or restricted fetal activity making it difficult for the fetus to turn
Grande multiparity - lax abdominal and uterine muscles allows movement and may lead to an unstable lie
(Mayes 2012)
Fetal and placental causes of breech presentation
Oligohydramnios - reduced liqour volume restricts the ability of the fetus to turn in the uterus. The condition may also be associated with fetal abnormalities and fetal compromise
Placenta location - placenta praevia may prevent the fetal head from fitting into the lower uterine segment and entering the pelvis
Fetal abnormalities - hydrocephalus can prevent the fetal head engaging in the pelvis
Multiple pregnancy - usually insufficient space to turn
Polyhydramnios - over distension of the uterus enables the fetus to be more mobile
Prematurity - increased incidence at earlier gestation as smaller fetus has greater space
Impaired fetal growth, short umbilical cord and fetal death - compromised fetus may result in decreased fetal activity
(Mayes 2012)
What is ECV?
RCOG (2017) advise that women with a term breech presentation should be offered external cephalic version (ECV) unless there is an absolute contraindication. It is the manipulation of the fetus, through the maternal abdomen, to a cephalic presentation
Contraindications for ECV
- Absolute reason for LSCS
- Placenta praevia
- Multiple pregnancy
- Rhesus isoimmunisation
- Vaginal bleeding with 7
days - SROM
- IUD
If ECV is unsuccessful …
RCOG (2017) advise that women who have breech presentation at term following an ECV should be counselled on the risks and benefits of planned vaginal breech delivery versus a planned caesarean section
Benefits of planned caesarean section
- Leads to a small reduction in perinatal mortality compared to vaginal delivery
- Avoidance of stillbirth after 39/40
- Avoidance of intrapartum risk
(RCOG 2017)
Risks of caesarean section
- Needs to be balances against the potential adverse outcomes (damage to the bowel or bladder and increased chance of stillbirth in future pregnancies RCOG 2019)
- Small increase in immediate complications for the mother compared to vaginal birth
(RCOG 2017)
Risks of perinatal mortality with caesarean section and vaginal birth
Caesarean after 39/40 = 0.5/1000
Planned vaginal breech birth = 2.0/1000
Planned cephalic birth = 1.0/1000
(RCOG 2017)
Benefits of planned vaginal breech birth
- A selection of appropriate pregnancies and skilled intrapartum care may allow planned vaginal breech birth to be nearly as safe as planned vaginal cephalic birth
- Small reduced risk of immediate complications for the mother compared to planned CS but the risk is highest with emergency CS which is needed in approximately 40% of planned vaginal breech birth
(RCOG 2012) - No shown increase in the risk of long term morbidity for babies
(RCOG 2017)
Risks of planned vaginal breech birth
- Increased risk of low APGAR scores and serious short
- Small increased risk of perinatal morality
(RCOG 2017)
Hannah term breech trail
Found breech vaginal deliveries to be unsafe which lead to routine caesareans. A follow up trail 10 years later showed there was no increased long term risk, even with short term consequences
Breech positions
- Left sacroanterior
- Left sacrolateral
- Left sacroposterior
- Right sacroanterior
- Right sacrolateral
- Right sacroposterior
(Mayes 2012)
What breech positions allow descent?
With the breech in either the left or right sacroanterior position and good contractions, there is descent
(Mayes 2012)
Mechanisms of vaginal breech delivery
- Compaction - descent with increasing flexion
- Internal rotation of buttock - the anterior buttock hits the pelvic floor and rotates forwards lying under the symphysis pubis. The bitrochanteric diameter (10cm) is now in the AP diameter
- Lateral flexion of the body - the anterior buttock escapes under symphysis pubis, the posterior buttock sweeps the perineum
- Restitution of the buttock - the anterior buttock turns to the mother’s left
- Internal rotation of the shoulders - uterine contractions and the weight of the baby brings the shoulders onto the pelvic floor. They enter the pelvis in the right oblique and the anterior shoulder fits the pelvic floor and rotates
- Birth of the shoulders - the anterior shoulder escapes under the symphysis and the posterior shoulder passes over the perineum
- Internal rotation of the head - as the baby hangs the weight aids descent and rotation
- Birth of the head by flexion
(Mayes 2012)
Epidural with breech deliveries
No evidence to support routine epidural anaesthesia but may increase the risk of intervention
(Prompt 2017)
Who needs to be informed on admission of a vaginal breech delivery?
Senior midwife Senior obstetrician Anaesthetist Theatre staff Paeds (Prompt 2017)
Fetal monitoring during vaginal breech delivery
CTG should be recommended to women as is likely to improve neonatal outcomes
(Prompt 2017)
Augmentation of breech vaginal delivery
Oxytocin is not recommended but the recent RCOG (2017) guidelines suggests that it may be considered if there is epidural anaesthesia in situ and the contraction frequency is less than 4:10
(Prompt 2017)
Assisted breech delivery
- Hands off the breech!!!
- If the fetal legs do not spontaneously deliver, inserting the index finger behind the thigh to flex the knee and abduct the leg may gentle disengage them. However, if the practitioner is prepared to wait they will usually deliver as the trunk descends
- With the next contraction, the shoulder blades appear; the arms, which are normally flexed across the chest, will usually slip out on their own and the shoulders are born in the anteroposterior diameter of the pelvis outlet. The head at this stage is entering the transverse or oblique diameter of the pelvic inlet. Let the baby hang there when the body is born
- Loveset’s manoeuvre
- Mauriceau Smellie Veit manoeuvre
(Mayes 2012)
Loveset’s manoeuvre
If the arms do not deliver spontaneously, gentle hold the baby around the bony part of the pelvis and rotate the baby through 90° to try and release the anterior arm. Sweep the arm down in front of the fact. If necessary repeat rotating in the opposite direction to release the other arm
(Mayes 2012)
Mauriceau Smellie Veit manoeuvre
Is an effective method of delivering the fetal head. The practitioner supports the baby with the legs straddling their left arm; three fingers slide into the vagina, feeling for the baby’s cheekbones. The ring and index fingers rest on the cheekbones while the middle finger applies pressure to the chin. The index and ring fingers of the right hand are hooked over the baby’s shoulders, to apply traction, while the middle finger presses on the occiput to aid flexion. Suprapubic pressure may be applied if needed
(Mayes 2012)
Burns-Marshall manoeuvre
👎 is where the baby is delivered by grasping the ankles and using slight traction, directing the trunk upwards in a wide arc over the women’s abdomen. DO NOT PERFORM!!!!!
(Mayes 2012)
Fetal risks associated with vaginal breech birth
- Intrapartum death
- Intracranial haemorrhage
- Hypoxic ischaemic
encephalopathy - Brachial plexus injury
- Rupture of the liver, kidney
and spleen - Dislocation of the neck,
shoulder or hip - Fractured clavicle, humerus
or femur - Cord prolapse
- Occipital diastasis and
cerebellar injury
(Prompt 2017)
Incidence of cord prolapse
Approximately 0.1-0.6% of all births
(Mayes 2012)
More common in breech deliveries
Difference between cord presentation and cord prolapse
Cord presentation = occurs when a loop of cord lies below the presenting part of the fetus, with the membranes still intact
Cord prolapse = occurs when the membranes rupture and the cord descends below the presenting part
(Mayes 2012)
Antenatal risk factors for cord prolapse
- Breech presentation
- Multiparity
- Fetal congenital
abnormalities - Unstable lie
- Oblique or transverse lie
- Polyhydramnios
- ECV
- Low birth weight
(Prompt 2017)
Intrapartum risk factors for cord prolapse
- ARM (especially with a high presenting part) - Unengaged presenting part - Prematurity - Internal podalic version - Second twin - Fetal scalp electrode application - Large balloon catheter IOL (Prompt 2017)
Recognising cord prolapse
- Early diagnosis is important
- May be obvious when there
is a loop of umbilical cord
protruding through the
vulva, however it is not
always apparent and may
only be found on VE - Cord prolapse should be
suspected when there is an
abnormal HR pattern in the
presence of ruptured
membranes
(Prompt 2017)
Who needs to be called for help for a cord prolapse?
Senior midwife Additional midwife staff Experienced obstetrician Anaesthetist Theatre team Neonatal team (Prompt 2017)
What to do immediately after diagnosing cord prolapse?
CALL FOR HELP
Cord compression should be minimised by elevating the presenting part. This can be done by maternal positioning, digital elevation or bladder filling
(Prompt 2017)
Maternal positioning to elevate the presenting part during cord prolapse
Traditionally recommended the knee-chest, face-down position. However, not ideal for transportation. Therefore the exaggerated Sim’s position (left lateral with a pillow under the left hip) with or without Trendelenburg (tilted bed so that the women’s head is lower than her pelvis) may be used instead.
(Prompt 2017)
Digital elevation of the presenting part during cord prolapse
Gloved fingers should be kept within the vagina to elevate the presenting part. This reduces compression of the cord, particularly during the contractions
(Prompt 2017)
What to do during a cord prolapse if the umbilical cord has prolapsed outside the vagina?
Handling of the cord may cause vasopasm and therefore replacing the cord into the vagina is not recommended. No evidence to support the practice of covering exposed cord with sterile gauze soaked in warm saline
(Prompt 2017)
Bladder filling during a cord prolapse
If the decision to birth interval is likely to be prolonged e.g. ambulance transfer needed, bladder filling may be considered. Insert a foley catheter and fill the bladder with sterile 0.9% sodium chloride, using an intravenous infusion set. Catheter should be clamped once 500ml has been instilled. Need to empty the bladder before birth is attempted.
(Prompt 2017)
Assessment for birth for cord prolapse
If cervix not fully dilated, a cat 1 CS should be performed. This is aiming to deliver within 30 minutes. If fully dilated, consider operative vaginal delivery, considering using forceps or ventouse.
(Prompt 2017)
Post birth care for cord prolapse
- Paired cord gases should be taken to assess neonatal condition - Ensure documentation of event, as well as risk management reporting forms - Debrief parents during and offer the opportunity after to discuss what happened (Prompt 2017)
Risks of cord prolapse to the fetus
- Hypoxia when the cord is compressed - Cooling, drying or handling of the cord may cause the umbilical vessels to go unto spasm, and affect the blood supply to the fetus (Mayes 2012)
Risk of cord prolapse to the mother
- Operative delivery and anaesthesia - Haemorrhage - Sepsis - Psychological trauma and potential impact on the mother-child relationship (Mayes 2012)
