Breech presentation

Question 1

Etiology

Answer 1

1. Something filling the lower segment->placenta preaevia or fibroids
2. Extension of the legs can prevent flexion of trunk and further rotation
3. +ratio of amniotic fluid to fetal size= allowing +fetal movement
4. Multiples->fetuses restricting the movement of the other
5. Fetal malformation may prevent cephalic presentations

Question 2

Risk factors

Answer 2

1. Nulliparity
2. Female
3. SGA, preterm
4. Maternal uterine abnormality
5. Female congenital abnormality

Question 3

Types

Answer 3

1. Both knees extended= frank breech, most common
2. Both knees flexed= flexed breech, complete
3. One knee flexed, one extended= incomplete breech
4. Hips extended= single or double footling->very small babies

Question 4

Diagnosis

Answer 4

1. Abdominal palpation-> no head palpable in lower, ballotable in upper
2. Vaginal confirms no head in pelvis, identify position of fetal sacrum, station of breech. Exclude cord prolapse and nuchal cord.
3. Investigations->USS

Question 5

Risks of breech

Answer 5

1. 2-3 X mortality (preterm)
2. Hypoxia rarely->cord prolapse and slow delivery of head
3. Maternal->PE, infection, bleeding, damage to bladder and bowel, slow recovery from delivery

Question 6

Management pre-labour

Answer 6

1. From 37 weeks can attempt external cephalic versio
2. Plan delivery before 41 weeks
3. CT scan standing lateral + USS to determine size if not reverting
4. If any complications ?C section at 38-39 weeks

Question 7

Process of external cephalic version, contraindications, if Rh-ve, if succes/no success

Answer 7

1. ECV + tocolytic
2. Listen to fetal heart before and after
3. Contraindications
   Uterine scar from previous C section
   HTN in other
   Ruptured membranes
   Planned c section anyway
   Multiples
   APH
4. If Rh-ve give anti-D
5. If successful->monitor weekly to ensure remains in cephalic position
6. If unsuccuessful->cousel re route of delivery, breech vaginal vs caesarean.

Question 8

Reasons for unsuccessful ECV

Answer 8

1. Breech too engaged
2. Uterus/abdominal wall too tense
3. Fetal abnormal, twins
4. Do USS

Question 9

Management during labour: first, second, third

Answer 9

1. First stage
   +risk of premature
   rupture of membrane
   Vaginal examination to exclude cord prolpase
   Epidural–> allows analgesia and option for operative Mx if
   required
2. Second stage
   Pelvis manouvre->Lovsett
   Mariceau Smellie Veit manouvre
   Propped up dorsal position, bed needs to be able to allow lithotomy
   Need experienced Obs/Anesthetist/Pediatrician
   Arms normally crossed on chest
   Legs delivered–> hand down, then occiput–> hands in mouth, forceps?
   Delivered face to perineum
   Mouth/nose cleared of mucus
   At time of crowning->?episiotomy
3. Third stage
   Placenta delivered normally
   Syntometrine given when delivery of head as +risk of PPH

Question 10

Counselling about breech risks

Answer 10

1. Due to no moulding, unable to determine if baby’s head is too big
2. 1 in 20 risk of neonatal death during vaginal birth
3. Cord prolapse also more common
4. Term breech trial in Lancet 2000 showed 3 X mortality/morbidity with breech
5. Most will be born safely, many will die/brain damage.
6. If home birth, worse outcomes.
7. If >4000g ++risk
8. If primi, Xreassurance that she has delivered baby
9. Options are C section or ECV
10. 40% chance of reverting to cephalic with ECV, small risk to baby and cord->may need C section
11. Possible will change position any time up until labour, less likely if frank breech.

Question 11

Explaining ECV

Answer 11

1. Should be performed at 36-37 weeks
2. Before this baby may turn spontaneously
3. Perform where facilities available for emergency C section
4. ContraI are: APH, HTN, uterine scar, multiples
5. Monitor fetus before and after
6. Tocolytic 30 mins before procedure
7. Direct damage to baby, cord entanglement and placental abruption
8. Gently dislodging buttocks from mother’s pelvis and somersaulting into cephalic position
9. Rh -ve mothers should be given anti-D

Question 12

Why is my baby in breech

Answer 12

1. Something obstructing lower segment
2. Uterine abnormalities
3. Some babies prefer position
4. +amniotic fluid
5. SGA

Question 13

Brief explanation and booking of C section

Answer 13

1. Booked at 39 weeks, to avoid emergency if goes into labour
2. Regional anaesthesia
3. Will remain awake
4. One support person in the room
5. Can usually go home after 24 hours if well
6. 60-70% chance of VBAC in next pregnancy
7. Explain risks of procedure (2 in 10 000 risk of death)
8. Consent form
9. Bloods->FBC, G&H
10. Anesthetic review
11. Book in theatre

Question 14

Management of mastitis

Answer 14

1. Can continue breastfeeding
2. Diflucloxacillin 10 days
3. Panadeine forte
4. Heat packs
5. Follow up

Question 15

Cause of postpartum pyrexia

Answer 15

1. Urinary tract infection
2. Endometritis
3. Wound infection
4. Basal atelectasis and pneumonia
5. Mastitis
6. DVT
7. Incidental->another non-post partum related cause