VAGINAL BREECH DELIVERY Flashcards by Joseph Uche

Define breech presentation

Breech presentation occurs when the fetus lies longitudinally with the buttocks presenting in the lower pole of the uterus

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the most common form of malpresentation in pregnancy

breech presentation

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Percentage of breech at term

3 - 4%

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Percentage of breech with premature delivery

25%

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Flexed hips, extended knees bilaterally

FRANK (EXTENDED BREECH)

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Both hips / knees flexed

COMPLETE BREECH

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Describe FOOTLING BREECH

One (single footling, breech) or both (double footling breech) legs extend below level of buttocks

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Another name for frank breech

Extended breech
Flexed hips, extended knees bilaterally

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Another name for complete breech

Flexed breech
Both hips / knees flexed

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5 fetal causes of breech presentation

Prematurity
Fetal malformations
–Hydrocephalus/anencephaly
Polar placentation
–Cornual
–Praevia
Genetic disorders (causing fetal hypotonia)
–Trisomies 13, 18, 21
–Potter syndrome
–Myotonic dystrophy
Abnormalities of liquor volume
–Polyhydramnios
–Oligohydramnios

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4 maternal causes of breech presentation

Pelvic tumours
Uterine anomalies (recurrent breech presentation)
– Bicornuate/septate uterus
Contracted pelvis
High parity

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3 clinical examinations for the diagnosis of breech presentation

Leopold’s manouvre
—Firm, rounded fetal head
ballotable in fundus
Fetal heart audible above
umbilicus
Pelvic examination
—Soft irregular breech

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ULTRASOUND CONFIRMS DIAGNOSIS AND EXCLUDES:

Placenta praevia
Multiple pregnancy
Skeletal abnormalities
Hydrocephalus
Spina bifida
Fetal ascites
Abdominal tumours

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T/F: Ultrasound Scan confirms degree of extension/flexion of fetal head

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T/F: X-ray can be used in the diagnosis of breech in the absence of USS

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Antepartum management of breech involves – and –

Anticipate spontaneous version

Counsel on risks of delivery options

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3 modalities of breech management

External cephalic version

Elective caesarean section

Planned vaginal delivery

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ECV is employed for – and –

Singleton breech

Non-vertex second twin

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At what GA is ECV performed

36 - 37 weeks

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5 Requirements for ECV

Ultrasound
2 Cardiotocographic monitoring
Tocolysis (controversial)
Regional Anesthesia—optional
Facilities for caesarean section

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Mean success rate of ECV

60%

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T/F: Higher success of ECV in Africans

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Success rate of ECV

35 – 85%

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6 Factors Associated with failure of ECV

Obesity
Engagement of the breech
Oligohydramnios
Posterior positioning of fetal back
Fibroids
Congenital uterine anomalies

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8 Complications of ECV

Feto – maternal transfusion Placental abruption Uterine rupture Cord accident Amniotic fluid embolism Preterm labour/rupture of membranes Fetal distress Fetal demise

3 risks of vaginal breech delivery compared with cephalic delivery

Cord compression/prolapse Difficulty in delivering shoulders Difficulty in delivering the head

9 antepartum criteria for vaginal breech delivery

1. Frank breech presentation 2. Gestational age ≥ 34 weeks 3. Estimated fetal weight of 2000 – 3500g 4. Flexed fetal head 5. Normal clinical/radiological pelvimetry --Inlet: Transverse 11.5cm/AP10.5cm -- Cavity: Transverse 10.0cm/AP 11.5cm 6. No indication for caesarean section 7. Previable fetus 8. Congenital anomaly 9. Presentation in advanced labour

For vaginal breech delivery GA should be

≥ 34 weeks

For planned vaginal breech delivery the EFW should be

2000 – 3500g

For planned vaginal breech delivery the transverse and AP diameter of the pelvic inlet should be

Transverse 11.5cm/AP10.5cm

For planned vaginal breech delivery the transverse and AP diameter of the pelvic cavity should be

Transverse 10.0cm/AP 11.5cm

For planned vaginal breech delivery the type of breech should be

Frank breech presentation

T/F: The fetal head should be flexed for planned vaginal breech delivery

9 aspects of intrapartum management of breech vaginal delivery

1. Normal progression first/second stage 2. Avoidance of induction/augmentation 3. Avoidance of breech extraction 4. Continuous electronic fetal monitoring 5. Policy of non-interference until spontaneous delivery of breech up to the umbilicus 6. Early recourse to caesarean section 7. Theatre must be available 8. Anesthesia must be available 9. Informed consent

In the intrapartum management of vaginal breech delivery, there should be Policy of non-interference until

spontaneous delivery of breech up to the umbilicus

9 indications for CS with breech presentation

1. If the Estimated Fetal Weight is < 1.5KG OR > 3.5kg 2. Contracted or Borderline Maternal Pelvis 3. Prolonged rupture of membranes 4. Footling Breech 5. Unengaged presenting part 6. PRIMIGRAVIDA 7. Hyperextended head 8. Poor obstetric history 9. Any other routine indication for CAESAREAN DELIVERY

EFW for CS in breech presentation

/= 3.5kg

3 methods of vaginal breech delivery

Spontaneous breech delivery Assisted breech delivery Breech extraction

Spontaneous Breech Delivery is

Delivery without assistance or obstetric manoeuvres to the baby’s body

Assisted Breech Delivery involves

The fetal body being guided through the birth canal by a series of properly-timed manoeuvres to deliver various parts of the body safely, taking advantage of maternal expulsive efforts

Breech Extraction involves

The whole of the fetal body being extracted by the accoucheur without the assistance of maternal efforts

When is Zatuchni Andros scoring system used in vaginal breech delivery

if unbooked or if the Breech Presentation is just being diagnosed in labour

T/F: The assessment of Zatuchni Andros score is designed to be made at the onset of labour

The 6 indices assessed in the Zatuchni Andros prognostic score are

1. Parity 2. Previous vaginal breech delivery (baby >2.5kg) 3. Gestational age 4. Estimated fetal weight 5. Cervical dilatation 6. Station

The highest possible score in Zatuchni scoring system is

The highest point for any one criteria in the zatuchni scoring system is

The lowest point for any one criteria in the zatuchni scoring system is

The possible points for parity in the zatuchni scoring system are

Primigravida = 0 Multigravida = 1

The points assigned to gestational age in the zatuchni scoring system are

>/=39 weeks --- 0 38 weeks --- 1

38 weeks GA has a score of --- in the Zatuchni scoring system

A score of 1 for GA in the ZAS is for

38 weeks

A score of 2 for GA is assigned for --- in ZAS

When is a score of 0 assigned for GA in ZAS

>/= 39 weeks

All indices in ZAS can have points 0, 1 or 2 except for which index

Parity which has either point 0 for primigravidity or 1 for multigravida

A point of 2 for EFW in ZAS is for

<3.1kg

A point of 1 for EFW in ZAS is for

3.1 to 3.6kg

A point of 0 for EFW in ZAS is for

>3.6kg

For previous vaginal breech delivery in ZAS, point 0 is for

None

For previous vaginal breech delivery in ZAS, point 1 is for

one previous breech delivery

For previous vaginal breech delivery in ZAS, point 2 is for

2 or more previous breech deliveries

A score of 2 for cervical dilation in ZAS is for

4cm or more

A score of 0 for cervical dilation in ZAS is for

2cm dilation

A score of 1 for cervical dilation in ZAS is for

3cm dilation

For station in ZAS 0 point is for

-3 station

For station in ZAS 1 point is for

station -2

For station in ZAS 2 points is for

station -1 or lower

A total score of 6 and above in ZAS indicates

a reasonable chance for a successful vaginal delivery.

--- total score in ZAS indicates a need for CS

A total score of 4 or 5 in ZAS indicates

a need for careful review of the mode of delivery. Explain the risk of proceeding with vaginal delivery to the parturient and consent. Otherwise, plan for caesarean delivery.

The easiest maternal position for intrapartum management of vaginal breech delivery is

propped -up dorsal position

When should the mother assume lithotomy position in vaginal breech delivery

after delivery of the baby’s body

The manoeuvre for delivering extended legs in assisted vaginal breech delivery

Pinnard's manoeuvre

The manoeuvre for delivering nuchal arms in assisted vaginal breech

Lovset manoeuvre

3 indications for breech extraction

Delivery of the second twin in twin gestation. Delay in the second stage of labour with fetal compromise, or A dead fetus

T/F: Do not augment a patient with dysfunctional labour during breech delivery

T as this might be a pointer to underlying complications with subsequent poor outcome.