Obs - Abnormal lie and breech

Question 1

what is nuchal arm and when does it occur?

Answer 1

situation in vaginal breech delivery during which one or both arms are found around the back of the head/neck, interfering with delivery.

when one tries to pull out a breech presenting fetus during vaginal delivery

Question 2

list some causes of abnormal lie?

Answer 2

Circumstances that allow more room for turn - most common causes:

1. Polyhydramnios
2. High parity

Preventing turn:
Twin pregnancy
Uterine abnormalities

Preventing engagement:
Placenta praevia

Question 3

how is unstable lie managed?

Answer 3

No action needed before 37 weeks

ECV from 37 weeks - External cephalic version - (though may turn back, and may spontaneously turn before 41 wks). 50% success rate

Tocoloytic - MgSO4 ; if uterine tone high - pre ECV

persistently abnormal lie:

• vaginal breech delivery if suitable
• CSection: also if eco contraindicated

Question 4

define breech presentation

Answer 4

presentating part of the fetus that occupies the lower segment of the uterus is the buttocks

Question 5

how is breech diagnosed?

Answer 5

USS:

also helps determine original causes/abnormality

Question 6

complications of breech?

Answer 6

Higher rates of long term neurological handicap
Increased risk of cord prolapse
Head may get trapped  death in breech VD

Question 7

what precautions must be taken when performing ECV?

Answer 7

USS guided

CTG is performed BEFORE? and straight after

anti-D given to Rh- women

Question 8

what are the contraindicatoins to ECV?

Answer 8

 Compromised fetus
 Contraindications to vaginal delivery
 Twins
 ROM
 Antepartum haemorrhage
IUGR - baby will beecome distressed if attempted

Question 9

Who ideally should not have a vaginal breech delivery?

prognosis of most breech?

What are the events/ interventions involved in breech delivery?

Answer 9

Who:

1. Not everyone can have vaginal breech, must be selected carefully.
2. More risky if; fetus >4kg, with evidence of fetal compromise; an extended head or footling legs

Prognosis:
Most deliver easily - if no complications - see above

Vaginal breech delivery:
Can only be spontaneous
Hands off delivery approach - do not pull baby
Do not induce or augment delivery - NO Oxytocin, (syntocinon etc?)

May require the following to help deliiver - in order;

1. episiotomy - once bum is seen
2. Lovset’s manœuvre - 2 fingers
3. Mauricaeu-Smellie-Veit manoeuvre
4. Forceps if above fail

Give Epidural analgesia

Question 10

why must USS be performed before ECV?

Answer 10

Polyhydramnios, oligohydramnios - ECV may not work

Macrosomic - ECV may not work

Question 11

what is lovset’s manoeevre? indication?

Answer 11

If arms cannot be reached (extended above the neck)

Placing hands around body with thumbs on sacrum and rotating baby 180 clockwise and then
counterclockwise with downward traction

Question 12

what is Mauricaeu-Smellie-Veit manoeuvre? indication?

Answer 12

Mauricaeu-Smellie-Veit manoeuvre performed once back of neck is visible:

o Support entire weight of fetus with one palm and forearm
o Use finger in mouth to guide head over the perineum and maintain flexion

• done to prevent over extension of head