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Obstetrics > RANZCOG guideline - BREECH > Flashcards

RANZCOG guideline - BREECH Flashcards

1
Q

What is the incidence of breech presentation at term?

A

3-4% beyond 37/40

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2
Q

What was the term breech trial and what was its impact on breech deliveries?

A

large RCT published in 2000
comparison of vaginal breech delivery vs elective C/S breech delivery
reported that perinatal morbidity and mortality was much higher in vaginal breech group vs C/S breech delivery 5% vs 1.6%

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3
Q

according to the term breech trial what was the rate of perinatal death in the vaginal breech group vs the elective CS breech group?

A

1.3% vs 0.3%

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4
Q

according to the term breech trial in 2000 what was the rate of serious perinatal morbidity in the elective CS breech delivery group vs vaginal breech delivery group?

A

1.4% vs 3.8%

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5
Q

What was the ‘fallout’ from the term breech trial

A
  • less vaginal breech deliveries, less expertise and training
  • now weigh up risk of CS for future pregnancies with risk of vaginal breech delivery
  • methodology of term breech trial questioned
  • individual case by case counselling now recommended
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6
Q

Reitberg et al published a paper titled “The effect of the Term breech Trial on medical intervention behaviour and neonatal outcome in the Netherlands: an analysis of 35,453 term breech deliveries”
What was the most significant finding?

A
  • NNT 175

- 175 C/S need to be offered to prevent one fetal death

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7
Q

What were the criticisms of the Term breech trial?

A
  • methodology criticised

- may not be generalisable to appropriately resourced and staffed centres in NZ and Australia

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8
Q

in 2016 Berhan and Haileamlak completed a meta analysis

What was their conclusion regarding the absolute risk of vaginal breech vs C/S breech delivery?

A

perinatal mortality was calculated to be 1:333 for vaginal breech delivery and 1:2000 for elective CS

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9
Q

what is required if a breech presentation is found late in third trimester?

A
  • an USS by a experienced clinician to determine whether any fetal or maternal reasons for a breech presentation exists
  • the USS should also be used to identify contraindications to ECV - amniotic fluid, placental location, hyperextension of fetal head, cord or footling breech
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10
Q

List 6 contraindications to ECV

A
  • Another reason for C/S exists (placenta praaevia)
  • APH within last 7 days
  • abnormal CTG
  • ruptured membranes
  • where there is rhesus iso-immunisation
  • multiple pregnancy
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11
Q

List 5 relative contraindications to ECV

A
  • oligohydramnios
  • SGA with abnormal dopplers
  • pre-eclampsia
  • major fetal anomalies
  • uterine anomalies (ECV may not be successful)
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12
Q

Non ECV methods to help with breech presentation - comments?

A
  • no evidence that postural management alone helps

- no evidence from recent trials that moxibustion is effective for version of breech presentation

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13
Q

what percentage of breech babies at term currently have C/S

A

90%

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14
Q

what is the recommended timing of elective CS?

A

39/40

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15
Q

what are the 3 essential components of planned vaginal breech birth?

A
  • appropriate case selection
  • management according to a strict protocol
  • availability of skilled birth attendants
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16
Q

Where a vaginal delivery of a breech presentation is planned, appropriate infrastructure must include: (3)

A
  • Continuous electronic fetal heart monitoring in labour.
  • Immediate availability of skilled anaesthetic staff, facilities for immediate caesarean section, and paediatric resuscitation.
  • Availability of a suitably experienced midwife and obstetrician for all of labour with arrangements in place to manage shift changes and fatigue.
17
Q

List 6 contraindications to vaginal breech delivery?

A

• Cord presentation
• Fetal growth restriction (estimated fetal weight< 10th%) or macrosomia (estimated fetal weight >
3.8kg)
• Any presentation other than frank (extended) or complete (flexed) breech
• Hyperextension of fetal neck on ultrasound
• Evidence of antenatal fetal compromise (e.g. abnormal CTG)
• Fetal anomaly incompatible with vaginal delivery.

18
Q

What if a woman requires an IOL for another indication and has a term breech baby?

A
  • should not offer vaginal breech delivery if IOL is required
  • augmentation of labour should also be avoided as adequate progress may be the best indicator of adequate fetopelvic proportions
19
Q

how should 1st stage of labour be managed with a vaginal breech delivery?

A
  • same as with cephalic delivery but with continuous electronic fetal monitoring
  • if progress is slow, CS should be offered
  • the effect of epidural is unclear (may increase risk of intervention)
20
Q

how should 2nd stage of labour be managed for vaginal breech delivery?

A
  • passive second stage for 2 hours
  • if breech is not present at 2 hours, CS should be recommended
  • active pushing should not be encouraged until breech is visible
21
Q

What should you do if breech presentation first discovered in labour?

A
  • counsel regarding risks and benefits
  • offer emergency CS
  • POCT USS should be available
22
Q

how should a woman >25 with a viable fetus presenting in labour be counselled regarding MOD?

A
  • elective CS recommended
23
Q

For a woman presenting in labour between 22-24:6 with breech presentation, what mode of delivery should be recommended?

A
  • no evidence that CS is beneficial
  • perinatal mortality is dependent on factors other than the mode of delivery
  • CS should not be routinely recommended (as maternal morbidity therefore outweighs benefit)
24
Q

how do you deliver a breech baby vaginally?

A
  • discourage active pushing until breech visible
  • hands off approach - traction should be avoided
  • fetus grasped around pelvic girdle (not soft tissue)
  • do NOT hyperextend fetal neck
  • selective rather than routine episiotomy recommended
25
Q

describe the Lovset manouver

A
  • splinting the humerus and sweeping the arm downward across the fetal thorax, which should be rotated so the shoulder of the arm being delivered is anterior
  • the fetus is then rotated 180 degrees so the same manoeuvre can be achieved on the other side
26
Q

Describe the Pinard manouever

A
  • manouver to deliver the fetal legs

- pressure in the popliteal space of the knee, which results in external rotation of the thigh and flexion of the knee

27
Q

Describe the Mauriceau-Smellie-Veit maneuver

A

fetus supported on the forearm with the middle and index finger on the fetal maxillae and the other hand applying pressure to the fetal occiput (or with an assistant applying suprapubic pressure)

28
Q

What are the preparations that should be made to ready for fetal head entrapment at breech delivery?

A
  • anaesthetist contacted
  • adequate analgesia
  • tocolytic agents
  • familiarity with Duhrssen’s incisions of the cervix
29
Q

What is the Duhrssen’s incision?

A

an incision to resolve fetal head entrapment
- 2 and 10 oclock incision
+/- 6 o’clock incision

Obstetrics (28 decks)

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