Malposition/Malpresentation

Question 1

What are the risk factors for breech presentation?

Answer 1

• Maternal
  
  • Placental abnormalities (praevia, increta, percreta, accreta)
  • Uterine abnormalities
  • Grand multiparity → uterine laxity
  • Obstructed lower segments - i.e. fibroids, pelvic abnormalities
• Foetal
  
  • Multiple gestation
  • Prematurity
  • Foetal malformation
  • Polyhydramnios
  • Oligohydramnios
  • Macrosomia

Question 2

What are the signs and symptoms of breech presentation?

Answer 2

• Abdomen - palpable head at fundus, soft breech in pelvis
• Vaginal - soft presenting part, ischial tuberosities, anus or genitalia may be felt
  
  • Footling breech - foot felt or seen through cervix

Question 3

What are the appropriate investigations for a suspected breech presentation?

Answer 3

USS to confirm

Question 4

What are the types of breech presentation?

Answer 4

Question 5

What features are high risk for a breech presentation?

Answer 5

• Hyperextended neck
• High EFW
• Low EFW
• Footling presentation
• Evidence of antenatal foetal compromise

Question 6

What information and procedures should be given for a breech presentation before delivery?

Answer 6

• Offer ECV / External Cephalic Version
  
  • 50-60% success rate
  • Risk of Foetal distress → emergency CS or going into labour
• If ECV unsuccessful/declined = Council risks and benefits of vaginal delivery vs. CS
  
  • Benefits of CS:
    
    • Small reduction in perinatal mortality
    • Planned vaginal birth increases risk of low Apgar scores and short-term complications
  • Risks of CS:
    
    • Small increased risk of immediate complications for the mother
      
      • Higher with emergency C-section - needed in 40% of vaginal breech birth
    • Risk of complications in future pregnancy
• Women near active 2^nd stage should NOT routinely be offered C-section
• Induction of labour is not recommended
• Use continuous CTG

Question 7

What is the management of a vaginal breech delivery?

Answer 7

• ‘Hands off’ approach
  
  • If handling is needed, put thumbs on the sacrum and fingers on the ASIS of the baby
• Pinard manoeuvre = poke baby in popliteal fossa → baby bends at their knees
• Baby’s head stuck = winging of the scapulae
  
  • Rotate baby into the transverse position and pull the anterior arm down = Loveset’s manoeuvre
  • If second arm hasn’t delivered, rotate baby into opposite anterior position and pull other arm down
  • If the head remains stuck, perform Mauriceau-Smellie-Veit manoeuvre
  • If this doesn’t work, use forceps
• Very dangerous if footling
• Other considerations: G&S, X-match, FBC, CTG, make sure theatre is ready
• Avoid induction if possible

Question 8

What counselling should be given to women with a baby in a breech presentation?

Answer 8

• Risk Factors = uterine malformations, fibroids, placenta praevia, poly/oligohydramnios, foetal anomaly, prematurity
• Explain what breech means
• Offer ECV and explain risks → 50% success rate, placental abruption, foetal distress requiring an emergency CS
• Explain the benefits and risks of vaginal breech and C-section
  
  • Vaginal - if successful, has fewest complications, however, 40% risk of needing an emergency C-section
  • C-section - small reduction in perinatal mortality, implications on future pregnancy (placenta praevia, VBAC, uterine rupture)

Question 9

What are the signs and symptoms of an unstable lie?

Answer 9

• Transverse lie
  
  • Abdomen - no presenting part in pelvis, uterus appears wide, fundal height may be low
  • Vaginal - no presenting part
• Face - facial landmarks felt
• Brow - supraorbital ridges or base of nose felt

Question 10

What are the appropriate investigations for suspected unstable lie?

Answer 10

USS to confirm lie

Question 11

What is the management of an unstable lie?

Answer 11

• 80% revert to longitudinal lie before labour
• Transverse lie → CS (ECV with 50% success):
  
  • Increased risk of cord prolapses
• Brow
  
  • Face
    
    • Mentoposterior = CS
    • Mentoanterior = SVD
• Compound (foetal arm along head) → manage expectantly