Malpresentation

Question 1

Name 3 types breech

Answer 1

• complete: flexion foetal hips + knees
• incomplete: extension one or both hips
• frank: flexion at hips, extension knees

Question 2

Name 6 maternal factors that puts at risk of delivering breech

Answer 2

• Uterine anomalies
• prior breech
• fibroids
• Placenta praevia
• grand multiparity
• contracted maternal pelvis
• pelvic tumours

Question 3

Name 6 foetal risk factors breech

Answer 3

• Prematurity
• polyhydramnios
• multiple gestation
• short umbilical cord
• foetal anomalies: anencephaly, hydrocephalus
• abnormal foetal motor ability

Question 4

Name 7 foetal complications breech

Answer 4

• Increased congenital abnormalities
• preterm birth
• birth trauma
• low apgar
• acidosis,
• head/ arm entrapment
• head hyperextension

Question 5

Name 3 complications external cephalic version

Answer 5

• Urgent caesarean delivery for foetal distress
• abruptio placenta
• onset of labour

Question 6

Name 8 contra-indications external cephalic version

Answer 6

• Any c/i to vaginal delivery
• multiple gestation
• Rom, oligohydramnios
• known uterine / foetal anomaly
• uterine bleeding
• active phase labour
• scarred uterus
• relative: HIV, pre-eclampsia

Question 7

When is external cephalic version attempted, and what must be done before attempt (4)

Answer 7

• breech at 36 weeks or more
• no c/i and informed consent
• Ctg
• beta mimetic tocolysis with salbutamol

Question 8

Management failed external cephalic version and remains breech?

Answer 8

Don’t attempt again. Do caesarean at 39 weeks

Question 9

Mode of delivery term breech? (8)

Answer 9

Vaginal. Elective caesarean if:

• large foetus > 3500g
• unfavourable pelvis
• hyper-extended head
• incomplete/footling breech
• foetal distress
• severe IUGR
• lack experienced obstetric + anaesthetic personal

Question 10

Mode of delivery pre term breech?

Answer 10

Vaginal
C/s if <1500g

Question 11

Name 8 prerequisites for breech labour

Answer 11

• Facilities for c/s immediately available
• iv line
• continuous ctg
• (epidural helps)
• latent phase <8 hours
• progress > 1 cm/hour on partogram
• no oxytocin augmentation
• experienced Dr
• must be descent of breech

Question 12

Manage breech delivery. (10)

Answer 12

• Lithotomy , mom to bear down with contractions
• consider episiotomy when breech distending perineum
• allow foetal buttocks and trunk to deliver
• as umbilicus appears, pull down loop of cord!
• nb that foetal back face up at all times. Forward rotation of trunk may be necessary by holding body in 2 hands with thumbs on sacrum + index over femoral heads,
• foetus must descend spontaneously to where scapulae become visible.
• preferably spontaneous delivery of arms but if delay: splint and sweep. Insert finger over shoulder to elbow to splint humerus and sweep arm laterally over chest.
• gentle forward traction will similarly facilitate delivery of posterior arm.
• if hands above head: Lovset’s maneuver.
• as foetal head reach pelvic floor, foetal back should face directly up. Baby’s body can hang on arm of Dr to assist descent of head. Deliver head once hair line visible.
• suction mouth + nostrils as foetal face appears. Delivery head should be carefully controlled with mom not pushing too hard or at all
• Maneuvers eg mariceau - smellie - fit, forceps, burns - Marshall, wigand - Martins

Question 13

Describe LoVset’s manoeuvre

Answer 13

When foetal arms and shoulders extended or folded around neck

• Rotate foetal trunk during breech by holding hips and turn half a circle keeping back up and apply downward traction, so that arm that was posterior becomes anterior and can be delivered under pubic arch
• place 2 fingers on upper part arm to assist. Draw arm down over chest
• deliver and arm by turn baby back half a circle and repeat.

Question 14

Describe Mauriceau Smellie Veit manoeuvre

Answer 14

To deliver head in breech

• rest body on arm
• first and third fingers on cheekbones,second finger in baby’s mouth to pull jaw down and flex head.
• other hand to grasp baby’s shoulders

Ask assistant to push on pubic bone as head delivers.

Question 15

Which forceps used in breech and how

Answer 15

Piper forceps

For after - coming head to keep head flexed. Apply forceps from below while assistant hold baby

Question 16

Describe burns Marshall maneuver

Answer 16

Allow breech to hang by its weight until nape neck visible.
Then hold both feet upwards and let deliver

Question 17

Describe Pinard manoeuvre

Answer 17

For breech

If extended knees prevent easy delivery
Assist by flexing at knees and gently delivering each leg