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OBSTETRICS > SINGLETON BREECH DELIVERY > Flashcards

SINGLETON BREECH DELIVERY Flashcards

1
Q

What is the typical presentation of a fetus near term?

A

“The fetus spontaneously assumes a cephalic presentation near term.”

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2
Q

What percentage of singleton deliveries at term have breech presentation?

A

“Breech presentation persists in 2 to 5 percent of singleton deliveries at term.”

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3
Q

What are the types of breech presentations?

A

“Frank breech, Complete and Incomplete (Footling)”

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4
Q

Describe a frank breech presentation.

A

“Lower extremities are flexed at the hips and extended at the knees

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5
Q

Describe a complete breech presentation.

A

“Both hips and one or both knees are flexed.”

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6
Q

Describe an incomplete breech presentation.

A

“One or both hips are extended, As a result, one or both feet or knees lie below the breech, and thus a foot or knee is lowermost in the birth canal.

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7
Q

What is a footling breech?

A

“An incomplete breech with one or both feet below the breech.”

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8
Q

What is a ‘stargazing fetus’?

A

“A breech fetus with extreme hyperextension of the neck.”

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9
Q

What is the term ‘flying fetus’ used for?

A

“A transverse lie with extreme hyperextension of the fetal neck.”

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10
Q

What are some risks associated with hyperextended neck in a breech fetus?

A

“Risk of cervical spinal cord injury during vaginal delivery

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11
Q

What fetal lie is more common earlier in pregnancy and why?

A

“Breech presentation

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12
Q

What are risk factors for breech presentation?

A

“Extremes of amniotic fluid volume , fetal anomalies, structural uterine abnormalities, placenta previa, nulliparity, increased maternal age, female fetal gender, prior breech delivery, and size that is small for gestational age

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13
Q

What is the recurrence rate of breech presentation after one and two prior breech deliveries?

A

“10% after one breech delivery and 28% after two.”

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14
Q

What does Leopold maneuver assess in breech presentation?

A

“Fetal presentation

1st maneuver - the hard, round fetal head occupies the fundus.
2nd maneuver- identifies the hard, broad back to be on one side of the abdomen and the knobby small parts on the other.
3rd maneuver - is not engaged, the softer breech is movable above the pelvic inlet.
After engagement
4th maneuver - shows the breech to be beneath the symphysis.

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15
Q

What is palpable during cervical examination with frank breech?

A

“Fetal ischial tuberosities, sacrum and anus
NOT PALPABLE - fetal feet

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16
Q

How is fetal sacrum position used in diagnosis?

A

“It designates fetal position relative to maternal pelvis

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17
Q

What factors influence the choice of delivery route for breech fetuses?

A

“Maternal parity and pelvic dimensions; coexistent pregnancy complications; provider experience; patient preference; hospital capabilities; and fetal size, anatomy, and gestational age

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18
Q

What are the benefits of planned cesarean delivery for term breech fetuses?

A

“Lower perinatal mortality (3 per 1000 vs. 13 per 1000) and reduced serious neonatal morbidity (1.4% vs. 3.8%).”

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19
Q

What are some contraindications for vaginal breech delivery?

A

“Severe growth restriction & Oligohydramnios”

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20
Q

What factors favor successful vaginal delivery for term breech fetuses?

A

“Spontaneous labor & Normal Labor curve”

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21
Q

What is the survival advantage of cesarean delivery for preterm breech fetuses?

A

“Higher neonatal survival compared with vaginal delivery

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22
Q

What are common maternal risks of cesarean delivery for breech presentation?

A

“Genital tract lacerations

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23
Q

What are common fetal risks in breech presentation?

A

“Prematurity

Umbilical cord prolapse - more frequent with breech fetuses and with breech vaginal delivery

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24
Q

What are the essential actions upon arrival to the labor unit for labor management?

A

Monitor fetal heart rate and uterine contractions, ensure immediate recruitment of a breech extraction provider, assistant, anesthesia personnel, and a newborn resuscitation-trained individual; obtain IV access.

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25
Q

Why is assessing cervical dilation, membrane status, and presenting part station essential?

A

It guides labor management and indicates whether further interventions, such as pelvimetry or cesarean delivery, are needed.

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26
Q

What are the minimum fetal monitoring requirements during the first stage of labor?

A

Record fetal heart rate every 15 minutes and consider continuous electronic monitoring.

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27
Q

What should be done immediately after membranes rupture during labor?

A

Perform a vaginal examination and monitor the fetal heart rate for the first 5 to 10 minutes to assess for cord prolapse risk.

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28
Q

What are the advantages of continuous epidural analgesia during labor?

A

Better pain relief and increased pelvic relaxation for potential fetal manipulation.

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29
Q

When should cesarean delivery be considered during the passive second stage of labor?

A

If the breech is not visible after 1½ to 2 hours of the passive phase.

30
Q

What is the preferred approach during the active phase of the second stage of labor?

A

A hands-off approach to allow spontaneous delivery, while encouraging active pushing.

31
Q

What are the risks associated with an active second stage lasting more than 20 minutes?

A

Increased risk of adverse neonatal outcomes.

32
Q

What are the key considerations for labor induction in term breech pregnancies?

A

Higher NICU admission rates with induction but similar neonatal outcomes compared to spontaneous labor.

33
Q

Why is steady cervical progress important in breech labor?

A

It indicates adequate pelvic capacity and helps guide labor management.

34
Q

What are the three methods of vaginal breech delivery?

A
  1. Spontaneous breech delivery
  2. Partial breech extraction
  3. Total breech extraction.
35
Q

What is the initial sequence of cardinal movements in spontaneous breech delivery?

A
  1. Engagement and descent with the bitrochanteric diameter in an oblique pelvic diameter,
    followed by
  2. Internal rotation.
36
Q

How is the posterior hip delivered in spontaneous breech delivery?

A

The posterior hip is forced over the perineum through lateral flexion, allowing the fetus to straighten.

37
Q

What is a key maneuver to minimize fetal soft tissue injury during partial breech extraction?

A

Grasp the fetal pelvis with thumbs on the sacrum and fingers on the anterior superior iliac crests for delivery.

38
Q

How is the fetal leg delivered during partial breech extraction?

A

Splint the femur with fingers parallel to it, apply upward and lateral pressure, and gently deliver the leg away from the midline.

39
Q

What is a cardinal rule in successful breech extraction?

A

Apply steady, gentle downward traction until the lower halves of the scapulas are delivered.

40
Q

How is the posterior shoulder delivered if trunk rotation fails during partial breech extraction?

A

Draw the feet upward, align fingers along the humerus, and sweep the arm upward for delivery.

41
Q

What is a nuchal arm and how can it complicate delivery?

A

A nuchal arm occurs when one or both fetal arms lie across the back of the neck and become trapped at the pelvic inlet. This makes delivery more difficult.

42
Q

How can a right nuchal arm be addressed during delivery?

A

Rotate the fetus counterclockwise so the fetal back moves toward the maternal right. Friction from the birth canal draws the elbow toward the face.

43
Q

How can a left nuchal arm be addressed during delivery?

A

Rotate the fetus clockwise so the fetal back moves toward the maternal left.

44
Q

What can be done if manual rotation of a nuchal arm fails?

A

The fetus may need to be pushed to a roomier part of the pelvis. If still unsuccessful, the operator can extract the nuchal arm using downward pressure to flex the elbow and sweep the arm forward.

45
Q

What are common complications of extracting a nuchal arm?

A

Fractures of the humerus or clavicle are common.

46
Q

What is the Mauriceau maneuver used for?

A

It is used to deliver the aftercoming head of a breech fetus while maintaining head flexion with suprapubic pressure.

47
Q

What are Piper forceps, and when are they used?

A

Piper forceps are specialized instruments used to deliver the aftercoming head of a breech fetus when the Mauriceau maneuver is insufficient.

48
Q

How are the blades of Piper forceps applied during delivery?

A

The blades are guided upward along the fetal parietal bone. The left blade is held in the provider’s left hand, and the right hand helps guide it into place.

49
Q

What is the modified Prague maneuver used for?

A

It is used to deliver a breech fetus when the back fails to rotate anteriorly. One hand grasps the shoulders from below while the other draws the feet upward and over the maternal abdomen.

50
Q

What is head entrapment, and why is it an emergency?

A

Head entrapment occurs when the fetal head is stuck, often due to an incompletely dilated cervix or cephalopelvic disproportion, leading to significant cord compression.

51
Q

How can an incompletely dilated cervix causing head entrapment be managed?

A

The cervix may be manually slipped over the occiput or treated with Dührssen incisions. Relaxation with halogenated anesthesia or a cesarean may also be needed.

52
Q

What is the Zavanelli maneuver?

A

It involves replacing the fetus higher into the uterus to allow for cesarean delivery, often used for shoulder dystocia or entrapped aftercoming head.

53
Q

Why are Dührssen incisions performed, and how are they placed?

A

Dührssen incisions help relieve cervical constriction during head entrapment. They are typically cut at 2 and 10 o’clock, and sometimes at 6 o’clock, to minimize bleeding.

54
Q

What is symphysiotomy, and when might it be used?

A

Symphysiotomy involves surgically dividing the pubic symphysis to enlarge the pelvic opening. It may be used in cases of cephalopelvic disproportion.

55
Q

What is used to aid in delivering a frank breech during total extraction?

A

Moderate traction using a finger in each groin, aided by a generous episiotomy.

56
Q

What is the Pinard maneuver and when is it used?

A

A procedure to convert a frank breech to a footling breech by external rotation of the hip, typically used if decomposition inside the uterine cavity is required.

57
Q

Under what conditions does the Pinard maneuver become extremely difficult?

A

If amniotic fluid is scant and the uterus is tightly contracted.

58
Q

What medications may be used to relax the uterus during breech delivery?

A
  • General anesthesia
  • magnesium sulfate (IV)
  • nitroglycerin
  • betamimetic agent.
59
Q

How is total breech extraction performed for incomplete or complete breech presentation?

A

The provider introduces a hand through the vagina, grasps both feet, applies gentle traction, and sequentially delivers the legs, hips, and body.

60
Q

What should be done if only one fetal foot can be grasped during breech extraction?

A

The single foot is held, and the opposite hand is used to locate and bring down the second foot.

61
Q

What is external cephalic version (ECV)?

A

A manipulation performed through the abdominal wall to convert a breech or transverse lie to a cephalic presentation.

62
Q

When is ECV generally attempted?

A

After 37 0/7 weeks’ gestation.

63
Q

What are the absolute contraindications for ECV?

A

Placenta previa or any situation where vaginal delivery is not an option.

64
Q

What factors improve the chances of ECV success?

A
  • Multiparity
  • unengaged presenting part
  • nonanterior placenta
  • nonobese patient
  • abundant amniotic fluid.
65
Q

What are some potential complications of ECV?

A
  • Placental abruption
  • Preterm labor
  • fetal compromise
  • bradycardia
  • uterine rupture
  • fetomaternal hemorrhage.
66
Q

What are the steps in performing ECV?

A
  1. Position the patient in left lateral tilt
  2. use ultrasound guidance
  3. apply forward roll or backward flip pressure to fetal poles
  4. monitor fetal heart rate.
67
Q

What is the preferred tocolytic agent for ECV, and what is its effect?

A

Terbutaline; it raises the success rate of ECV by relaxing the uterus.

68
Q

What analgesia options may improve ECV success rates?

A

Epidural or spinal analgesia coupled with tocolysis.

69
Q

What is moxibustion and its role in breech version?

A

A traditional Chinese medicine technique using heat to increase fetal movement and promote spontaneous breech version.

70
Q

Factors Favoring Cesarean Delivery of the Breech Fetus

Clinical characteristics:

A
  • Lack of operator experience
  • Patient request for cesarean delivery
  • Prior perinatal death or neonatal birth trauma
71
Q

Factors Favoring Cesarean Delivery of the Breech Fetus

Sonographic fetal characteristics:

A

Large fetus: >3800 to 4000 g
Severe fetal-growth restriction; term weight <2500 to 2800 g
Oligohydramnios
Fetal anomaly incompatible with vaginal delivery
Incomplete breech presentation
Hyperextended neck
Apparently healthy, viable preterm fetus either with active labor or with indicated delivery

72
Q

Factors Favoring Cesarean Delivery of the Breech Fetus

Maternal characteristics:

A

Pelvic contraction or unfavorable pelvic shape determined clinically or with pelvimetry
Prior cesarean delivery

OBSTETRICS (13 decks)

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