Malpresentation Flashcards

1
Q

what are the definitions for the following types of breech delivery
-Spontaneous vaginal breech
-Assisted vaginal breech
-Breech extraction
-Breech caesarean

A
  1. Spontaneous vaginal breech
    -No manoeuvres required to deliver baby
  2. Assisted vaginal breech
    -Spontaneous decent until umbilicus visible at introitus then manoeuvres
  3. Breech extraction
    -Manual descent of the baby by grasping the leg. Indicated only for second twin delivery
  4. Breech delivery by caesarean
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2
Q

Discuss delivery of a vaginal breech
-First stage (4 points)
-Second stage (10 points)

A
  1. First stage
    -Check delivery not contra-indicated
    -Scan to confirm presentation
    -Offer epidural
    -Avoid oxytocin unless poor uterine activity following epidural
  2. Second stage
    -Avoid handling the breech
    -Avoid maternal effort until breech is distending introitus
    -Allow trunk and lower limbs to deliver spontaneously
    -Avoid touching umbilical cord to avoid vasospasm
    -Consider Pinards manoeuvre to release legs
    -Ensure baby is sacro-anterior and handle the boney prominences over illiac crests to reduce risk to soft tissue
    -Allow spontaneous descent until inferior aspect of scapula are visible
    -Deliver arms using Lovsetts manoeuvres
    -Support baby and allow spontaneous descent until nape of neck is visible. Avoid traction to avoid head extension
    -Deliver after coming head either:
    -Spontaneously if possible
    - Suprapubic pressure to maintain head flexion
    -Mauricea-Smellie- Veit manouvre
    -Burns Marshall technique
    -With aid of forceps
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3
Q

Discuss Pinards manoeuvres
-When to use (1)
-How to do it (3 steps)

A
  1. When to use
    -To delivery the lower limbs once umbilicus of baby is at introitus
  2. How to do Pinards manoeuvres
    -Pass hand along baby’s thigh till it reaches the popliteal fossa
    -Apply pressure laterally to popliteal fossa to flex at knee
    -Find foot as knee flexes and deliver
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4
Q

Discuss Lovsett’s manoeuvres
-When to do (1)
-How to do (4)

A
  1. When to do
    -For the delivery of the upper limbs in assisted vaginal breech
  2. How to do
    -Apply a femopelvic grip with both hands and thumbs parallel to vertebral column on boney prominences to avoid soft tissue trauma
    -Rotate baby 90 degree until sacro transverse and one shoulder is anterior
    -Sweep finger over shoulder to antecubital fossa and flex arm at elbow to release.
    -Rotate baby back through 180 degrees and repeat arm release manoeuvre in the same maner
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5
Q

Discuss Mauricea-Smellie-Veit manoeurvre
-When to do (1)
-How to do (3)

A
  1. When to do
    -To deliver the after coming head
  2. How to do
    -Place baby in horse riding position over forearm
    -Use first and third fingers of same arm and place on baby’s cheek bone. Apply gentle flexion
    -Use third finger of other hand and place on occiput and apply gentle flexion
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6
Q

Discuss Burns Marshall technique
-When to use (1)
-How to do (3)

A
  1. When to use
    -Use to deliver the after coming head
  2. How to do
    -Allow the baby to hang to allow maximum head flexion
    -When nape of neck is visible hold baby and swing feet in long arc towards mother’s abdomen
    -May need to apply forceps to continue head flexion
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7
Q

Discuss forceps use in vaginal breech delivery
-How often used (1)
-When use is indicated (1)
-How to use (4)

A
  1. How often used
    -Used in up to 20% of vaginal breech deliveries
  2. When to use
    -Indicated if MSV manoeuvre is unsuccessful after 2-3 attempts
  3. How to use
    -Have an assistant gently lift the baby without undue traction
    -Apply in the same manner as for cephalic presentation
    -Apply gentle downward traction until baby’s chin seen
    -Apply gentle upward traction there after
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8
Q

Discuss manoeuvres to manage head entrapment in vaginal breech delivery.
-Manoeuvre (5)
-Associated risks with manoeuvre

A
  1. McRoberts - same as for shoulder dystocia
  2. Uterine relaxation - GTN/Terbutaline
    -Maternal tachycardia and atony (PPH)
  3. Durhrssen’s incision - cervical incision at 2, 10 +/- 6 o’clock
    -Extension into lower segment
    -Extension into broad ligament and haemorrhage
    -Injury to uterine vessels, ureter, bladder
    -Cervical incompetence in future pregnancy
  4. Symphysiotomy - incision through SP to increase space to delivery fetal head
    -Pelvic instability, slow recovery
  5. Zavanelli’s manoeuvre - replace baby back into cavity and CS
    -Cervical injury and subsequent incompetence
    -Complications of CS
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9
Q

Outline the basic steps for managing head entrapment in vaginal breech

A
  1. Call for help of most senior obstetrician, anaesthetist, paeds
  2. Perform McRoberts
  3. Apply suprapubic pressure for head flexion
  4. Attempt MSV manouvre
  5. Rotate baby to sacrotransverse
  6. Administer tocolytics
  7. Attempt Forceps
  8. Attempt Duhrssen’s incisions
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10
Q

Discuss occiputo-posterior presentation
-Incidence (2)
-Causes (2)
-Risks (5)
-Findings on exam (3 topics)
-Delivery outcomes (4)

A
  1. Incidence
    -1/3rd of babies at onset of labour are OP
    -5-10% are persistent OP
  2. Causes
    -Certain pelvic shapes with wide posterior
    -Use of early epidural at higher station or in latent phase
  3. Risks
    -Prolonged labour by 1-2 hrs
    -CS for failure to progress
    -Increased fetal distress
    -Increase of complex perineal tears
    -No impact on perinatal mortality
  4. Exam findings
    -Hx: back pain
    -Abdo: concave, fetal limbs felt anterior, impression on o/5th but high station
    -VE: Posterior fontanelle felt posteriorly, Anterior fontanelle anterior, free presacral space, persistent cervical lip
  5. Delivery outcomes
    -Spontaneous delivery in 45%
    -Can use oxy to encourage rotation
    -Can use manual rotation with rotational delivery
    -Can do instrumental or CS
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11
Q

Discuss Shoulder presentation
-Cause (1)
-Risks (3)
-Diagnosis (3)
-Management (3 options)

A
  1. Cause
    -Usually a result of unstable lie
  2. Risks
    -Hand prolapse
    -Cord prolapse
    -Obstructed labour and uterine rupture
  3. Diagnosis
    -Abdo palpation
    -VE
    -USS
  4. Management
    -ECV
    -CS - may need vertical incision if backdown
    -Stabilising IOL - ECV, Stabilised ARM, Oxy
    -Do if >39/40 and favourable Cx
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12
Q

Discuss face presentation
-Diameter (1)
-Cause (1)
-Diagnosis
-Types (2)
-Management (6)

A
  1. Diameter - 9.5cm submentobregmatic
  2. Cause - hyperextension of baby’s head
  3. Diagnosis
    -Palpable malar eminences and baby’s mouth on VE
  4. Types
    -Mento-anterior (jaw at front) - can delivery vaginally
    -Mento-posterior (jaw at back) - can’t delivery vaginally
  5. Management
    -Only mento-anterior can delivery vaginally
    -CS if mento-posterior
    -Consider oxy to increase head flexion
    -Forceps OK but ventouse contraindicated
    -Avoid FBS and FSE
    -Large episiotomy may be beneficial
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13
Q

Discuss brow presentation
-Diameter
-Cause
-Management (3)

A
  1. Diameter - 13.5cm mentoverticle
  2. Very deflexed head
  3. Management
    -May be part of transition
    -If head at spines then requires CS
    -If baby small and mother a multip may deliver vaginally
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