Malpresentation

Question 1

What are the types of breech presentation?

Answer 1

Types:

• Frank: legs extended alongside body with feet lying beside head
• Complete: legs flexed
• Footing: lower limbs present over os

Question 2

How do you diagnose breech position?

Answer 2

History:

• PHx
• tenderness under costal margin

Examination:

• Inspection
• Palpation - fundal height, Pawlik’s grip (no longer used, use two hands), presentation - feels softer

Investigation:

• CTG
• Ultrasound

Question 3

What are Leopold’s Maneuvers?

Answer 3

1. Fundal Grip
   
   • facing palpate upper abdomen with both hands
   • head hard, trunk soft and symmetric
2. Umbilical grip
   
   • determine the location of the fetal back - gentle but deep pressure.
   • right hand steadies abdomen while left palpates.
3. 1st Pelvic grip
   
   • two hands as not to be unconfortable. Just above the pubic symphysis
4. 2nd Pelvic grip
   
   • try and feel brow and if you see it then the occiput is felt instead the baby is coming.

Question 4

What is external cephalic version? What are some risks? How often is it successful?

Answer 4

Process:

• conversion of breech to cephalic via maternal abdominal wall - ITS PAINFUL
• external CTG before/after +/- during
• US for AFI confirmation -
• give tocolytic (relax uterine wall) + anaesthetic + anti-D.
• at 36-37weeks

Success Rate:

• 20% reality but 60% is quoted - try 3 times
• improves with relaxation using terbutamine
• more difficult with nulliparous, obese or extended fetal legs

Risks:

• PROM, abruption, uterine rupture, cord entanglement

Contraindications:

• antepartum bleeding,
• multiple pregnancy,
• placenta privia
• oligohydramnios,
• uterine scar

Question 5

What are some risk factors for transverse and breech positions?

Answer 5

Uterus:

• uterine changes: fibroids, bicornuate, CS previously
• polyhydramnios - more fluid
• oligohydramnios
• prematurity (rounder uterus)
• high parity - reduced abdominal wall tone
• placenta in lower uterine segment

Fetus:

• multiple pregnancies
• major fetal malformations (e.g. hydrocephalus)

Question 6

What is the management of malpresentation?

Answer 6

• ECV at 36-37 weeks if possible - many revert
• CS
  
  • if persists beyond 38weeks needs to be admited
  • If water breaks assess for cord prolapse
    
    • vaginal examination
    • turn on all 4s - keep hand in the vagina.