Breech / Malpresentation

Question 1

Types of breech presentation

Answer 1

Frank - buttocks first, legs extended, hips flexed

Complete - buttocks first, legs and hips flexed

Footling - one or both feet first

Question 2

RF for breech presentation (uterine, foetal, maternal)

Answer 2

uterine - placenta praaevia, fibroids, malformation, multiparity

foetus - multiple, premature, polyhydramnios, foetal abnormalities (hydrocephalus, anencephaly)

maternal - previous breech, pelvic tumours

Question 3

Risks of delivery in breech presentation

Answer 3

cord compression and prolapse - longer than in cephalic delivery, makes resuscitation harder

foetal head entrapment

intracranial haemorrhage

asphyxia

maternal - ruptured uterus, cervical tear, perineal trauma, PPH

Question 4

Management of breech presentation

Answer 4

external cephalic version
c section
vaginal - frank and complete, not footling

Question 5

Counselling for external cephalic version

Answer 5

indication - breech 36/40 or 37/40
before - confirm position on USS, CTG, mother supine, IV salbutamol (tocolytic)
during - gently rotate foetus keeping head flexed ‘front flip’
benefits - cheap, simple, non invasive, 50% success
risks - very low complications, cord compression, placental abruption, ROM
alternatives - vaginal delivery or c section

Question 6

Vaginal breech delivery indication and CI

Answer 6

indication - maternal preference with a frank or complete breech and after failed ECV

CI - footling or kneeling, cord presentation, IUGR, macrosmia, foetal head extension, unsuitable maternal pelvis

Question 7

Technique of breech vaginal birth

Answer 7

• episiotomy
• make sure buttocks and anus present first
• deliver legs one at a time, flexing at knee and sweeping leg laterally
• rotate baby so a shoulder is anterior, sweep arm downwards and out by flexing at elbow
• make baby face mothers back
• keep head flexed by applying downward pressure on cheeks, hold baby in same forearm, guide baby out by lifting upwards

Question 8

OSCE for breech presentation - headings to cover

Answer 8

Brief Hx - current pregnancy, obstetric hx, medical and surgical hx, social

Exam - request findings, SFH, lie, presentation, engagement, BP (rule out PET)

Ix - USS check position

Mx

1. ECV
2. C/S
3. vaginal

Question 9

complications and management of occipito-posterior malposition

Answer 9

issue: head cannot fully flex so a larger diameter is presented (occipital-frontal)

complications - prolonged painful labour, obstruction, birth trauma, PPH

counsel - VB can still progress, increased risk of complications
analgesia - epidural recommended
prolonged labour options - induce, instrumental delivery, C/S

Question 10

management of face presentation

Answer 10

mento-anterior - normal SVB

mento-posterior - C/S

Question 11

management of brow presentation

Answer 11

C/S

worst presentation - largest diameter (occipito-mental)

Question 12

risk factors for obstructed labour

Answer 12

<18yo
small pelvis

macrosomia
malpresentation or malposition

Question 13

shoulder dystocia

- clinical signs and complications

Answer 13

turtle sign - head presented then retracts as it recoils against perineum

brachial plexus palsies
limb fractures
maternal birth trauma

Question 14

management of shoulder dystocia

Answer 14

HELPER
Help - obstetrician, midwife, paediatrician, anaesthetist
Episiotomy - J shaped on R side perineum
Legs - mother flex hips and legs up to chest, slightly abduct hips
Pressure - suprapubic
Enter - doctors hand for rotational maneuvres
Remove posterior or anterior arm

Question 15

Erb’s palsy

• what is it
• clinical features

Answer 15

C5-C6 nerve root injury in brachial plexus

atrophy of deltoid and biceps
waiter’s tip position - arm hangs limply, medially rotated, forearm extended and pronated

Question 16

indications and prerequisites for instrumental delivery

Answer 16

indications:
delayed 2nd stage of labour
foetal distress on CTG
maternal exhaustion

prerequisites:
vertex presentation 
full cervical dilation 
engaged head
station at or below ischial spines 
empty bladder
adequate analgesia