OGCO-C2.2 Management of non cephalic presentation in a singleton pregnancy at term

Question 1

When will breech presentation be dx?
What is the offered management?

Answer 1

36 weeks of gestation will dx breech presentation (will not likely change presentation later)
Women with breech presentation at term (37 weeks) should be offerred external cephalic version (ECV) unless there is an absolute contraindication.

Question 2

How are women diagnosed with transverse lie at 37 weeks managed?

Answer 2

• Admitted for monitoring from 37 weeks of gestation in view of the risk of cord prolapse following rupture of membranes and risk of obstructed labor.
• After ruling out unstable lie, ECV can be offered (evidence of use is limited) as successful procedure may allow vaginal birth. Women should be informed about risk of spontaneous reversion after a successful ECV, possibly due to the underlying cause associated with transverse lie.

Question 3

What is the mx of unstable lie that is diagnosed at 37-38 weeks?

Answer 3

• Should be admitted for monitoring for the same reasons as in transverse lie (risk of cord prolapse following rupture of membranes and risk of obstructed labor)
• Women can be offered stabilization induction after 39 weeks or elective Caesarean delivery

Question 4

What are the contraindications to ECV?

Answer 4

• Previous uterine scar (one previous caesearean section is a relative contraindication)
• Placenta praevia
• History of antepartum hemorrhage in the past 7 days
• Hypertension
• Oligohydraminos
• Intrauterine growth restriction, abnormal fetal Doppler or cardiotocography
• Major uterine anomalies
• Rhesus isoimmunization
• Condition that necessitates delivery, such as prelabour rupture of membranes, placenta abruption,
  severe pre-eclampsia

Question 5

What is Mx of patients with breech presentation/transverse lie who agree to ECV?

Answer 5

ECV done as day procedure. CTG and NST prior to procedure done. A growth scan within 1 week prior to procedure is needed.
0.25mg terbutaline diluted in 10ml normal saline and given in IV over 2-3 minutes. BP reading 5 mins after injection, after 2nd reading if normal start ECV.
ECV is limited to 10 mins.

After ECV, FHR checked with ultrasound. In case of persistent fetal bradycardia, the baby should be delivered via Emergency caesarean section.

When ECV successful for breech presentation. Patient discharged after reactive post ECV NST. Follow up appointment arranged at antenatal clinic in 1 week.

Following successful ECV for transverse lie, women should stay overnight and fetal presentation should be assessed on the nexdt day. Patient can be discharged if fetus remains cephalic presentation and follow up appointment at antenatal clinic 1 week later.
If ECV failed, elective C section arranged before discharge.

Question 6

How is ECV done for unstable lie?

Answer 6

ECV performed as part of stabilization induction for unstable lie, the procedure should be performed in labor ward and terbutaline is usually not required.
After successful cephalic version, fetal lie should be stabilized abdominally by assistant while rupture of membranes done and syntocinon IV infusion started. Care should be taken to exclude cord prolapse or presentation.

Test for fetomaternal hemorrhage (kleihauer test) and offered anti-D Ig (if mother is Rh-ve)

Question 7

What is the Mx for patients whose fetus in breech presentation but decline ECG?
What is the benefit of doing recommended Mx?

Answer 7

Risk and benefits of planned vaginal breech delivery vs planned C section should be discussed. Patient ifnormed that planned C section leads to a small reduction in perinatal mortality.

Reduced risk is due to 3 factors
* avoidance of stillbirth after 39 weeks of gestation
* Avoidance of intrapartum risks and risks of vaginal breech birth

Perinatal mortality: 0.5/1000 with c section after 39+0 weeks of gestation; and 2/1000 with planned vaignal breech birth.

Planned vaginal breech birth increases the risk of low Apgar scores and serious short term complications.
Elective C-section should be arragend at 38-39 weeks of gestation

Question 8

What is the Mx of patients who presented with breech presentation in labor?

Answer 8

If breech presentation dx before advancef labor at term, it is reasonable to offer the women emergency C section. Even if CS is planned, she could labor quickly before there is time to carry out CS. This is more likely to occur if she had previous vaginal delivery or she goes into preterm labor.
Option of vaginal breech delivery could be considered in patients presenting with advanced labor.