Malpresentation

Question 1

AN Mx of Breech presentation

Scenario 1 - primip, known uterine fibroid, breech presentation at 36/40

Answer 1

• USS
  1. ?cause of breech (PAD/Ut/anom)
  2. ?CI to ECV (FGR/Olig/doppler/nuchal)
• M risk - emCS/PPH
• F risk - head entrap/HIE/CP/SB
• MDI/Expertise…
• Counselling - ECV vs elCS

Counselling
- 3%, 8% turn at term
- 3-fold, term breech, adverse outcomes
- options - ECV vs elCS

1. ECV - OP, muscle relaxant, 70% success, CTG, +/-anti-D, 4% (NRCTG, small APH), 1:200 (0.5%) emCS, 3% revert, F/U RTS in OPC, check again @SOL/IOL
2. elCS - safer, future preg imp, surg risks, recovery, 39/40

PN F/U
- 6/52 hip USS

Question 2

Perform an ECV

Answer 2

• RTS - ?nuchal
• CTG pre
• Consent…
• OT availability
• IV access
• Empty bladder
• Muscle relaxant
• Dis-impact breech from pelvis
• Won’t do >4 attempts, max 10 minutes
• CTG post
• KH and Anti-D if rhesus -‘ve

Question 3

Mx of face/cord presentation in labor

Scenario 1 - 28yo G2P1, TF rural center in labor, on arrival unexpected face/cord presentation at 4cm

Scenario 2 - 31yo 25/40 DCDA in small private hospital p/w small volume APH with large cervical fibroid obstructing & open cervix -> PPROM -> cord prolapse en route to Tertiary hospital in ambulance

Answer 3

Obs Emergency
Team - simultaneous tasks
MDI - Obs/MW/anesthetic/Neonatal

• all 4s, knee to chest/head down
• elevate presenting part
• avoid touching cord (spasm)
• keep cord in vagina
• confirm FH, keep CTG on
• terbutaline/code green
• if transfer delay, fill bladder w IDC
• transfer to OT/IVC/G&S
• empty IDC if CS/GA CS
• lithotomy
• midline or wide pfannenstiel
• +/- classical +/- breech del
• paired cord gases
• neonatal team
• document/debrief

Face presentation
- MP = CS
- MA = can attempt VB, risk of CS
- notify senior obs
- check morph ? anomaly
- check labor progress
- exclude signs of obstruction (urine/temp)
- trial of labor +/- emCS if obstructed or NRCTG
- experienced accoucher
- avoid instrumental
- paeds at birth & rv PP

Question 4

Mx of breech presentation in labor

Scenario 1 - breech in labour - ?planned or unplanned

Scenario 2 - mannequin station, need to show assisted breech delivery, 28yo multip, 38/40, in labour arrives in BS, feet on view, birth imminent.

Answer 4

CI for vaginal breech - cord/footling presentation/IUGR/Macrosomia/hyperextension of neck/fetal anomaly incompatible with VD

Mx of breech in labour
- MDI
- Avail - OT/Expertise
- Adequate AN counselling
- Follow local guidelines
- footling/cord present -> CS
- RTS/CTG/IVC/Bloods
- Avoid amniotomy to reduce cord

• Intrapartum care
  Analgesia as per mother
  1st stage - CEFM
  2nd stage
• pref lithotomy/bladder empty
• delayed 2nd stage up to 2/24
• no pushing till breech on peri
• hands off - reduce stimulation
• umbi to delivery ~4min
• active mx if NRCTG/delay
• hands on iliac crest
• keep fetal back to pubis (Lovset’s)
• MSV+/-fundal pressure +/- forceps (shanks depressed) - in lithotomy
• active mx of 3rd stage
• cord gas
• paeds in room

Assisted breech birth - if poor foetal condition (colour/tone) or delay from but-head, umbi-head (e.g. keeping back anterior with gentle rotation without traction, Lovset’s & MSV +/- Forceps aftercoming head )

Unplanned
- Obs emerg
- Fetal wellbeing
- Confirm on RTS+Exam
- Exclude footling & cord -> emCS
- MDI - MW/Anaesthetic/OT
- Follow local guidelines
- Availability of expertise/OT
- Ed: risk vs benefit -> depends on immediacy of birth
- Clear communication & document
- Recommend Cat 1 emCS - depends on whether birth imminent
- Beware of cause of breech (e.g. undiagnosed previa/foetal anomaly)
- Once decided for emCS
- IVC/Blood/CTG/Tocolytic/Inform team
- +/- Piper if PTB
- postpartum - need hip USS in 6/52

Question 5

Mx of malpresentation in labour

Scenario 1 (x2) - transverse lie in labour @36/40

Scenario 2 - 43yo DCDA with demise of 1 twin earlier, PPROM @35/40 malpresentation in labor of leading twin

Answer 5

• Risk of cord - fetal distress/GA CS
• Obs emergency
• MDI - Obs/MW/anaesthetic/paed/OT
• Cat 1 emCS vs labor vs controlled ARM
  (latter 2 risk of cord prolpase + GA CS)
• Ensure fetal wellbeing: RTS/CTG/VE - dilation, cord +/- terbutaline
• Prep for OT: NBM/IVC/FBE/G&S/Consent/Communication wit pt/partner/team
• Intra-op: spinal/terb/intra-abdo version to cephalic or breech +/- LUS vs Classical
• Postop: debrief/LMWH/Breast feeding…

Note - consider classical if dorso-inferior (backdown) as may be challenging delivery and LUS poorly formed