Malpresentation Flashcards
1
Q
what are the definitions for the following types of breech delivery
-Spontaneous vaginal breech
-Assisted vaginal breech
-Breech extraction
-Breech caesarean
A
- Spontaneous vaginal breech
-No manoeuvres required to deliver baby - Assisted vaginal breech
-Spontaneous decent until umbilicus visible at introitus then manoeuvres - Breech extraction
-Manual descent of the baby by grasping the leg. Indicated only for second twin delivery - Breech delivery by caesarean
2
Q
Discuss delivery of a vaginal breech
-First stage (4 points)
-Second stage (10 points)
A
- First stage
-Check delivery not contra-indicated
-Scan to confirm presentation
-Offer epidural
-Avoid oxytocin unless poor uterine activity following epidural - Second stage
-Avoid handling the breech
-Avoid maternal effort until breech is distending introitus
-Allow trunk and lower limbs to deliver spontaneously
-Avoid touching umbilical cord to avoid vasospasm
-Consider Pinards manoeuvre to release legs
-Ensure baby is sacro-anterior and handle the boney prominences over illiac crests to reduce risk to soft tissue
-Allow spontaneous descent until inferior aspect of scapula are visible
-Deliver arms using Lovsetts manoeuvres
-Support baby and allow spontaneous descent until nape of neck is visible. Avoid traction to avoid head extension
-Deliver after coming head either:
-Spontaneously if possible
- Suprapubic pressure to maintain head flexion
-Mauricea-Smellie- Veit manouvre
-Burns Marshall technique
-With aid of forceps
3
Q
Discuss Pinards manoeuvres
-When to use (1)
-How to do it (3 steps)
A
- When to use
-To delivery the lower limbs once umbilicus of baby is at introitus - How to do Pinards manoeuvres
-Pass hand along baby’s thigh till it reaches the popliteal fossa
-Apply pressure laterally to popliteal fossa to flex at knee
-Find foot as knee flexes and deliver
4
Q
Discuss Lovsett’s manoeuvres
-When to do (1)
-How to do (4)
A
- When to do
-For the delivery of the upper limbs in assisted vaginal breech - How to do
-Apply a femopelvic grip with both hands and thumbs parallel to vertebral column on boney prominences to avoid soft tissue trauma
-Rotate baby 90 degree until sacro transverse and one shoulder is anterior
-Sweep finger over shoulder to antecubital fossa and flex arm at elbow to release.
-Rotate baby back through 180 degrees and repeat arm release manoeuvre in the same maner
5
Q
Discuss Mauricea-Smellie-Veit manoeurvre
-When to do (1)
-How to do (3)
A
- When to do
-To deliver the after coming head - How to do
-Place baby in horse riding position over forearm
-Use first and third fingers of same arm and place on baby’s cheek bone. Apply gentle flexion
-Use third finger of other hand and place on occiput and apply gentle flexion
6
Q
Discuss Burns Marshall technique
-When to use (1)
-How to do (3)
A
- When to use
-Use to deliver the after coming head - How to do
-Allow the baby to hang to allow maximum head flexion
-When nape of neck is visible hold baby and swing feet in long arc towards mother’s abdomen
-May need to apply forceps to continue head flexion
7
Q
Discuss forceps use in vaginal breech delivery
-How often used (1)
-When use is indicated (1)
-How to use (4)
A
- How often used
-Used in up to 20% of vaginal breech deliveries - When to use
-Indicated if MSV manoeuvre is unsuccessful after 2-3 attempts - How to use
-Have an assistant gently lift the baby without undue traction
-Apply in the same manner as for cephalic presentation
-Apply gentle downward traction until baby’s chin seen
-Apply gentle upward traction there after
8
Q
Discuss manoeuvres to manage head entrapment in vaginal breech delivery.
-Manoeuvre (5)
-Associated risks with manoeuvre
A
- McRoberts - same as for shoulder dystocia
- Uterine relaxation - GTN/Terbutaline
-Maternal tachycardia and atony (PPH) - Durhrssen’s incision - cervical incision at 2, 10 +/- 6 o’clock
-Extension into lower segment
-Extension into broad ligament and haemorrhage
-Injury to uterine vessels, ureter, bladder
-Cervical incompetence in future pregnancy - Symphysiotomy - incision through SP to increase space to delivery fetal head
-Pelvic instability, slow recovery - Zavanelli’s manoeuvre - replace baby back into cavity and CS
-Cervical injury and subsequent incompetence
-Complications of CS
9
Q
Outline the basic steps for managing head entrapment in vaginal breech
A
- Call for help of most senior obstetrician, anaesthetist, paeds
- Perform McRoberts
- Apply suprapubic pressure for head flexion
- Attempt MSV manouvre
- Rotate baby to sacrotransverse
- Administer tocolytics
- Attempt Forceps
- Attempt Duhrssen’s incisions
10
Q
Discuss occiputo-posterior presentation
-Incidence (2)
-Causes (2)
-Risks (5)
-Findings on exam (3 topics)
-Delivery outcomes (4)
A
- Incidence
-1/3rd of babies at onset of labour are OP
-5-10% are persistent OP - Causes
-Certain pelvic shapes with wide posterior
-Use of early epidural at higher station or in latent phase - Risks
-Prolonged labour by 1-2 hrs
-CS for failure to progress
-Increased fetal distress
-Increase of complex perineal tears
-No impact on perinatal mortality - Exam findings
-Hx: back pain
-Abdo: concave, fetal limbs felt anterior, impression on o/5th but high station
-VE: Posterior fontanelle felt posteriorly, Anterior fontanelle anterior, free presacral space, persistent cervical lip - Delivery outcomes
-Spontaneous delivery in 45%
-Can use oxy to encourage rotation
-Can use manual rotation with rotational delivery
-Can do instrumental or CS
11
Q
Discuss Shoulder presentation
-Cause (1)
-Risks (3)
-Diagnosis (3)
-Management (3 options)
A
- Cause
-Usually a result of unstable lie - Risks
-Hand prolapse
-Cord prolapse
-Obstructed labour and uterine rupture - Diagnosis
-Abdo palpation
-VE
-USS - Management
-ECV
-CS - may need vertical incision if backdown
-Stabilising IOL - ECV, Stabilised ARM, Oxy
-Do if >39/40 and favourable Cx
12
Q
Discuss face presentation
-Diameter (1)
-Cause (1)
-Diagnosis
-Types (2)
-Management (6)
A
- Diameter - 9.5cm submentobregmatic
- Cause - hyperextension of baby’s head
- Diagnosis
-Palpable malar eminences and baby’s mouth on VE - Types
-Mento-anterior (jaw at front) - can delivery vaginally
-Mento-posterior (jaw at back) - can’t delivery vaginally - Management
-Only mento-anterior can delivery vaginally
-CS if mento-posterior
-Consider oxy to increase head flexion
-Forceps OK but ventouse contraindicated
-Avoid FBS and FSE
-Large episiotomy may be beneficial
13
Q
Discuss brow presentation
-Diameter
-Cause
-Management (3)
A
- Diameter - 13.5cm mentoverticle
- Very deflexed head
- Management
-May be part of transition
-If head at spines then requires CS
-If baby small and mother a multip may deliver vaginally
