Malpresentation Flashcards
Discuss breech presentation
-Incidence at different gestations (<28/40, 32/40, Term)
-Classification and incidence of each (4)
-Risk factors (3 groups)
- Incidence
<28/40 - 30-40%
32/40 16%
Term 3-4%
-90% of breech babies are delivered by CS
Spontaneous version in nulliparous women >36/40 is <10% - Classification and incidence of each type of breech
-Complete breech - hips flexed, knees flexed 10%
-Footling breech (Incomplete) - hips and knees extended 25%
-Frank breech - hips and knees extended 65%
-Knee presentation - hips extended knees flexed - rare - Risk factors
Uterine factors
-Grandmultiparity
-Uterine abnormalities
-Fibroids
-Placenta praevia
Fetal factors
-IUGR/macrosomia
-Oligo/polyhydramnios
-Prematurity
-Multiple pregnancy
-Fetal structural anomaly - hydrocephaly/cystic hygroma
-Fetal movement abnormality
-Short umbilical cord
Pelvic factors
-Pelvic shape
-Pelvic tumours
Discuss antenatal management of breech babies
-Diagnosis and assessment (4)
-Management options (3)
- Diagnosis and assessment
-If suspected on palpation order USS to confirm diagnosis after 36/40
-If detected preterm rescan at 36/40
-On scan assess for type of breech, fetal and uterine abnormalities, placental position
-On scan look for factors which might prohibit vaginal breech: Nuchal cord, extended head, footling breech, cord presenting, EFW outside of range - Management options
-Offer ECV
-If ECV unsuccessful counsel options (CS vs Vaginal Breech)
-No evidence moxibustion or postural changes cause version
-CS should be in 39th week. Breech is a risk factor for late still birth
Discuss vaginal breech deliveries
-Overall incidence of risks of VB vs CS (4)
-Specific risks with VB (9)
Risks for vaginal breech
-2:1000 deaths with planned VB cf 0.5:1000 with CS
-Increased short term complications with VB
-No increased long term morbidity with VB
-No increased risk in maternal morbidity/mortality
-Approximately 40% of VB require emergency CS
2. Specific risks with VB
-Intrapartum death
-HIE
-Intracranial haemorrhage
-Dislocation of hip, shoulder, neck
-Rupture of kidney, spleen and liver
-Brachial plexus injury, fracture of clavicle, humorous, femur
-Cord prolapse -7% overall, 20% if footling
-Occipital diastasis or cerebellar injury
What are the criteria for vaginal breech delivery
-Contraindications (6)
-Requirements
- Contra-indications
-Cord or footling presentation
-Hyperextended neck
-Nuchal cord
-IUGR <10th (<2000g) or macrosomia >3.8kg
-Fetal anomaly incompatible with breech delivery
-Evidence of antenatal fetal compromise (AbN CTG) - Requirements
-Immediate access to CS facilities
-Availability of skilled birth attendant
-Adherence to strict protocol for management
-Continuous CTG
-Immediate access to paeds and anaesthetics
Discuss intrapartum management of vaginal breech (9)
-Don’t routinely offer breech if close to or in second stage
-IOL is usually not recommended
-Augmentation for slow progress should only be considered in the context of an epidural where contractions have died off
-Adequate passive decent in second stage is a pre-requisite to pushing in second stage. Pushing should start when the breech is at the perinium
-If breech is not visible after 2hrs of pushing CS is recommended
-Episiotomy should be selective not routine
-Evidence lacking for CTG
-Avoid FSB sampling from fetal rump
-Expedite delivery if :
-poor fetal condition on trace
-delivery between buttocks and head >5min
-Delivery between umbilicus and head >3mins
Discuss management of breech delivery in preterm babies (6)
-Evidence regarding term VB should not be extrapolated to preterm
-Recommend CS between 25-37/40 as 10% risk head entrapment
-Mode of delivery should be individualised
-Cochrane review doesn’t find any long or short term differences with MOD
-CS for breech at 22+5 - 24+6 is not routinely recommended. No clear benefit.
-If head entrapment occurs incise cervix at 10, 2 +/- 6 o’clock
-Manage the labour of a preterm breech the same as a term breech delivery
Discuss vaginal breech delivery with twins (3)
-Planned CS if the first twin is breech - limited evidence
-Routine EmCS for first breech twin in spont labour is not recommended - mode of delivery should be individualised
-Routine CS for breech presentation of second twin is not recommended in either term or preterm deliveries
What are the RANZCOG recommendations for breech delivery (12)
- All caregivers should be able to palpate presentation and have access to an USS to confirm presentation
- Women with breech babies in late third trimester should have a detailed USS to identify any factors contributing to malpresentation
- Women with breech presentation should be offered ECV if clinically appropriate
- ECV should be performed by a trained health practitioner with facilities if CS is required
- If the woman wants a vaginal breech then she should be counseled on the risks and benefits and there should be shared decision making
- Maternity units offering vaginal breech should have clear protocol and criteria for case selection
- If a woman presents in labour with breech presentation a discussion regarding EMCS vs VB should be had and presentation confirmed with USS
- VB birthing facilities must have access to continuous CTG, CS care, staff experienced in VB on all shifts
- All maternity units should train staff in managing breech deliveries for women who present in advanced labour
- When planned preterm delivery is required for maternal or fetal reasons >25/40 and the baby is breech then CS is recommended (i.e Don’t IOL)
- There is no clear benefit of doing CS over breech delivery for babies 22+0 - 24+6 and is not recommended
- ELCS should be done if the leading twin is breech
Discus the term breech trial
-Study details (2)
-Findings (5)
-Criticism (7)
- Study details
Type - multicentre unblinded RCT 26 countries 2088 women
Compared CS outcomes with VB outcomes - Outcomes
Perinatal mortality and neonatal morbidity sig lower in CS group (RR 0.33) 1.6% vs 5%
Perinatal death sig lower in CS group RR 0.23
Serious neonatal morbidity sig lower in CS group RR 0.36
Serious maternal morbidity same in both groups
No differences in long term consequences between groups - Criticism
Recruitment was in labour
Lack of clear protocols for inclusion and exclusion criteria
Ad hoc enrolment meant woman thought likely to have a successful VB not enrolled
Variable experience of health practitioners
Not all centres had immediate access to CS
Perinatal deaths not all caused by birth and if those which are are included then NS difference
Not blinded
CTG optional
Discuss newer research on safety of vaginal breech vs CS
-Premoda study (2 points)
-2016 Meta analysis (3 points)
- Premoda study
-Compared CS and trial of labour in breech women
-Based in France and multicentre. Centres all had experience with VB
-No difference in perinatal morality or serious neonatal morbidity - 2016 Meta-analysis
-Reduction in perinatal mortality to 1:2,000 with CS
-Reduction in perinatal mortality 1:333 with VB
-Absolute risks very small and almost equivalent to cephalic births
Discuss external cephalic version
-Definition
-Success rates (3)
-Timing (3)
- Definition
-Application of pressure to the maternal abdomen to turn the fetus into cephalic position - Success rates
-40% in nulliparous women
-60% in multiparous women
-Individual factors impact success rate - Timing
- From 36/40 in nulliparous women as reduced risk of reversion. But preferrable after 37/40
-From 37/40 in multiparous women
-No upper limit on gestation
Discuss external cephalic version
-Absolute contra-indications (8)
-Relative contra-indication (6)
- Absolute contra-indications
-Needing CS for other reasons
-Rh isoimmunisation
-APH in last 7 days
-Ruptured membranes
-Multiple pregnancy
-Abnormal CTG
-Abnormal uterine cavity
-Severe PET - Relative contraindications
-Previous CS - poor evidence against if 1 previous CS
-APH in pregnancy
-Active labour with intact membranes
-Major fetal anomalies
-Fetal growth restriction with AbN dopplers
-Oligohydramnios
-Maternal cardiac disease
-Unstable lie
-Proteinuric PET
Discuss external cephalic version
-Major risks (0.5% of time)
-Minor risks (4.3% of time)
-Other risks / SE
- Major risks
-1:200 require EMCS
-Placental abruption
-Cord prolapse
-Cord entanglement - Minor risks
-Transient CTG abnormalities - <3mins
-Ruptures membranes
-Minor APH - Other risks/SE
-Maternal discomfort
-SE to tocolytics - tachycardia
-Risk of reversion - 3%
-Labour after ECV slight increase risk of EMCS
Discuss external cephalic version
-Factors which increase success (6)
-Factors which decrease success (5)
- Factors that increase success
-Multiparous
-Rump not engaged
-Polyhydramnios
-Head easily palpable
-Non caucasian
-Use of tocolytics with betamimetics - Factors that decrease success
-Nulliparous
-Engaged rump
-Oligohydramnios
-Head extended
Discuss considerations for ECV procedure
- Fasting pre ECV and IV access not required routinely
- Give Anti-D if RH -ve
- Try a maximum of 4 times over a ten minute interval
- Caution with tocolysis in women with cardiac disease
