Wk 7: Mat emergencies 2 Flashcards
Define breech birth
where the presenting part of the fetus is the buttocks or feet and can be extended, flexed (frank) or footling.
What are predisposing factors for breech birth?
- nulliparity
- Previous breech birth
- Premature labour
- High parity
- Multiple pregnancy
- Polyhydramnios
- Oligohydramnios
- Uterine anomalies
- cornal pregnancy
- Maternal pelvic fibroids/tumour
- Placenta praevia
- Hydrocephaly/Anencephaly
- Fetal neuromuscular disorders
- Fetal head and neck tumours
- low lying palcenta
What are the SCV 2021 perinatal mortality statistics on both and which mode is safest?
- 0.5/1000 with ELCS for breech >39 weeks gestation
- 2.0/1000 planned vaginal breech birth >39/40
- 1.0/1000 with planned cephalic birth
What are the complications of breech birth?
- low APGARs
- other short term
- mortality
- risk of c/s
No long-term morbidity
What are the types of breech?
Complete: legs folded with deet at the level of the baby bottom
Footling: one or both feet emerge first
Frank: legs point up with feet by the baby’s head so the bottom emerges first
What are the management of breech?
- NVB if compatible
- offer ECV if not contraindicated
- if ECV unsuccessful= provide counselling on risks and benefits of a planned vaginal birth versus an ELCS.
B: reduced neonatal mortality and morbidity
R: complications with future pregnancies, risk fo repeat c/s, invasive placentation
What are some risks and benefits of an ECV?
Benifits
- baby becomes head down
- does not cause labour to begin
- can avoid unnecessary risks and complications of c/s aor vaginal breech
Risks
- bleeding
- abnormal CTG indicating c/s
- The risks to the mother of ECV are exceedingly small and relate to;
- possible effects from tocolysis
- rare complication of placental abruption
- For the fetus at term the risks are small if carried out with adequate surveillance by skilled personnel and with theatre facilities for immediate intervention in the event of a complication Breech presentation
When is an ECV not indicated?
- Antepartum haemorrhage in current pregnancy
- Ruptured membranes
- Multiple pregnancy
- Severe fetal abnormality
- Caesarean section necessary for other indications
- Previous caesarean section (relative contraindication)
- Poor fetal growth
- Significant hypertension or preeclampsia
- Uterine anomaly
- Cord around fetal neck (nuchal cord)
- Abnormal cardiotocograph (CTG)
- Hyperextension of the head
What are some alternatives to ECV?
- postural exercises
- acupuncture
- moxibustion
- chiropractic treatment
When is a planned vaginal breech not advised?
- a narrow pelvis
- your baby is presenting as a footling breech
- your baby is large (>3800g)
- your baby is small (<2000g)
- other reasons preventing a vaginal birth, such as lowlying placenta
- your doctor or hospital do not have the necessary skills
and resources for a vag
What medication may be used to support an ECV, why and what dose?
Tocolysis e.g terbutaline
- 0.5mg/ml
- used for ECV or after failed attempt
- relaxes the abdominal muscles to optimise the attempt
What is the success rate of an ECV?
with a trained operator, an overall ECV success rate of 40 -50% for nulliparous and 60 % for multiparous women can usually be achieved.
Explain key point of care when admitting to discharging someone for an ECV?
- ensure verbal consent obtained
- Abdominal palpation
- Review blood group- Anti D immunoglobulins may be required if a negative blood group
Maternal / fetal observations
- Mat HR + BP
- CTG for Senior medical review:
- Confirm breech and absence of a nuchal cord by u/s
- Consider IV if tocolysis is required
- Breech confirmed and CTG normal
ECV should be conducted by an experienced person
Post ECV
- CTG for 30 minutes or until CTG meets normal criteria
- Ultrasound to confirm success / exclude cord presentation
D/C
- ensure normal ECG
- document the procedure
- advise women to seek urgent medical advice is they experince;
- bleeding
- ruptured membranes
- reduced fetal movements
- abnormal abdominal pain
- commencement of labour
How should a woman be positioned for an ECV?
- recumbent
- wedge under hip to ensure left lateral tilt and thus placental perfusion
- lubrication may be used to aid manoeuvers
- commence the procedure by elevating the breech from maternal perlvis
- cephalic version may then be achieved by encouraging a ‘forward roll’
- u/s intermittently to confirm position, lie and HR
- expediting birth should be advised if any bleeding or unexplained abdo pain or if abnormal CTG persists
Explain the occurrence of a possible abnormal CTG post ECV?
A transient (less than 3 minutes) fetal bradycardia after ECV is common and benign.
- if it occurs continuous monitoring should commence/continue in a left lateral position.
- However if persistent and not improving after 6 minutes, should prompt preparation for category I caesarean section.
What is the management of an unsuccessful ECV?
- Consider tocolysis if due to uterine tone
- If ECV still unsuccessful with tocolysis, book elective LUSCS
What must be considered for women with a negative blood group before they have an ECV?
- as it is a potentially sensitising event a prophylactic does of anti-D is recommended
What are some alternative options to an ECV?
- spinning babies
- accupunture
- chiropractic care
- maxibustion
What are some good spinning babies techniques for breech babies?
Three favourite body balancing activities help the body more fully when used one after the other:
1. The Jiggle
2. Forward-leaning Inversion
3. Side-lying Release
= balance the pelvis and surrounding areas for comfort, birth preparation, and labour progress.
- move faschia and fluid around the area
- Add more gentle techniques to achieve even more consistent comfort in pregnancy and ease in childbirth.
- These three techniques, arranged in this order, tend to improve the comfort and fetal positioning for most pregnancies.
What are the benefits of accupunture in O+G and when/how often should it be used?
What is a specific point noted for breech correction?
Benefits
- help encourage baby to turn
- reduce stress
- to relax any tight muscles that might be preventing an ideal presentation
When
- 34-36 wks
Frequency
- 1-2 times per week
=According to Chinese medical texts, acupuncture point Bladder 67 (BL 67), or ‘Zhiyin’ in Chinese, which is located at the outer proximal corner of the toenail of the fifth toe, has been recommended as one of the main acupuncture points used to correct breech presentation (Cooperative Research 1980; Hou 1995; Neri 2004; Van den Berg 2008; Xia 1988).
However, there are other acupuncture points that are important, such as LI4, ST36, and SP6, that have been implicated in the treatment of fetal malposition in pregnancy. According to traditional Chinese medicine theories, these acupuncture points, including BL67, are needled to ‘tonify qi’ and blood, which have become deficient or stagnant in women with fetal malposition (Cheng 1999).
What is the benefit of chiropractic care in breech position correction?
= Aligning the pelvis and relaxing tight uterine ligaments attached to the fascia near the pelvis are why chiropractic adjustments can often help breech babies flip to a head-down position.
