Breech

Question 1

What is the definition of breech?

Answer 1

When fetus lies longitudinally with bum in the lower pole of uterus.

Question 2

Name the 4 variations of breech and their prevalence and risks if they have any

Answer 2

Complete or Flexed (10-15% of breech, risk of PROM/Cord Prolapse)

Extended or Frank (45-50% of breeches, HIGH risk of Cord Prolapse)

Footling (More common in Preterm)

Question 3

Name the 9 different causes/predisposing factors

Answer 3

• Prematurity
• Multiple pregnancy
• Abnormal liquor volume
• Firm abdominal muscles
• Contracted pelvis
• Uterine abnormalities
• Placenta Praevia, pelvic tumours, fibroids
• Grand multiparity

Question 4

How would you diagnose a Breech presentation antenatally?

Answer 4

Palpation
•Auscultation
•If >36/40  USS to confirm
•ECV to be considered
•Place and mode of delivery to be discusse

Question 5

How would you diagnose a Breech presentation postnatally?

Answer 5

VE

oBreech feels soft and irregular

oNo sutures

oAnus may be felt – meconium

oExternal genitalia may be felt
oFoot may be felt

Question 6

What can contribute to a successful ECV?

Answer 6

• Multiparity
• Frank breech
• Normal or increased amniotic fluid
• Relaxed uterus
• Suitable gestational age

Question 7

What is ECV and what does it stand for?

Answer 7

ECV is the manipulation of the fetus through the maternal abdomen, to a cephalic presentation, it stands for Eternal Cephalic Version

Question 8

Name the 13 contradictions of ECV

Answer 8

• Limited evidence
• Placental abruption
• Severe pre-eclampsia
• Abnormal dopplers or CTG
• Absolute reasons for LSCS
• Placenta Praevia
• Multiple pregnancies
• Rhesus isoimmunisation
• Vaginal bleeding within 7 days
• SROM
• Caution in oligohydramnios and hypertension
• History of LSCS controversial
• IUD

Question 9

Name the 5 different complications of ECV

Answer 9

• Fetal distress
• Placental abruption
• Fetomaternal haemorrhage
• ?? Cord entanglement
• Amniotic fluid embolism

Question 10

Name the 10 steps of the ECV procedure

Answer 10

• Empty bladder
• CTG
• Lie flat (Trendelenburg position)
• ? Tocolysis
• USS (intermittently throughout)
• Obstetrician disimpacts the breech
• By applying pressure to both poles the breech is rotated into a cephalic presentation (following its nose)
• CTG post procedure
• Observe for fetal distress, ROM, contractions, bleeding
• Kleihauer and Anti-D if Rh-ve

Question 11

What is the role of the midwife during the 1st stage of labour in a breech delivery?

Answer 11

• Basically same as cephalic presentation
• Membranes may rupture early
• Meconium stained liquor may be present secondary to compression of abdomen

Question 12

What is the role of the midwife during the 2nd stage of labour in a breech delivery?

Answer 12

• Confirm full dilation
• Consider position
• Availability of obstetrician, paediatrician, anaesthetist, theatre team (SOAPS)
• Be prepared – equipment available (obstetric forceps, warm towels, lithotomy poles, resuscitaire, discuss birth with mother

Question 13

Name the 6 breech positions

Answer 13

• LSA Left sacroanterior
• RSA Right sacroanterior
• LSLLeft sacrolateral
• RSL Right sacrolateral
• LSP Left sacroposterior
• RSP Right sacroposterior

Question 14

What are the steps of a vaginal breech delivery?

Answer 14

Anterior bum gits pelvic floor

Birth of bum

Posterior bum delivered

Legs delivered

Lovsets Manoruvre (to remove arms)

Internal rotation of shoulders

Delivery of posterior shoulder

Question 15

Name the 5 complications of Vaginal breech delivery

Answer 15

• Emergency LSCS
• Fetal Hypoxia–Cord prolapse; cord compression; premature separation of the placenta
• Impacted Breech–In obstructed labour
• Cord Prolapse–More common in flexed or footling breech as have ill-fitting presenting part
• Premature Separation of Placenta–Retraction of the uterus causes separation
• Maternal Trauma