Breech presentation Flashcards Preview

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Flashcards in Breech presentation Deck (15):
1

Etiology

1. Something filling the lower segment->placenta preaevia or fibroids
2. Extension of the legs can prevent flexion of trunk and further rotation
3. +ratio of amniotic fluid to fetal size= allowing +fetal movement
4. Multiples->fetuses restricting the movement of the other
5. Fetal malformation may prevent cephalic presentations

2

Risk factors

1. Nulliparity
2. Female
3. SGA, preterm
4. Maternal uterine abnormality
5. Female congenital abnormality

3

Types

1. Both knees extended= frank breech, most common
2. Both knees flexed= flexed breech, complete
3. One knee flexed, one extended= incomplete breech
4. Hips extended= single or double footling->very small babies

4

Diagnosis

1. Abdominal palpation-> no head palpable in lower, ballotable in upper
2. Vaginal confirms no head in pelvis, identify position of fetal sacrum, station of breech. Exclude cord prolapse and nuchal cord.
3. Investigations->USS

5

Risks of breech

1. 2-3 X mortality (preterm)
2. Hypoxia rarely->cord prolapse and slow delivery of head
3. Maternal->PE, infection, bleeding, damage to bladder and bowel, slow recovery from delivery

6

Management pre-labour

1. From 37 weeks can attempt external cephalic versio
2. Plan delivery before 41 weeks
3. CT scan standing lateral + USS to determine size if not reverting
4. If any complications ?C section at 38-39 weeks

7

Process of external cephalic version, contraindications, if Rh-ve, if succes/no success

1. ECV + tocolytic
2. Listen to fetal heart before and after
3. Contraindications
Uterine scar from previous C section
HTN in other
Ruptured membranes
Planned c section anyway
Multiples
APH
4. If Rh-ve give anti-D
5. If successful->monitor weekly to ensure remains in cephalic position
6. If unsuccuessful->cousel re route of delivery, breech vaginal vs caesarean.

8

Reasons for unsuccessful ECV

1. Breech too engaged
2. Uterus/abdominal wall too tense
3. Fetal abnormal, twins
4. Do USS

9

Management during labour: first, second, third

1. First stage
+risk of premature
rupture of membrane
Vaginal examination to exclude cord prolpase
Epidural--> allows analgesia and option for operative Mx if
required
2. Second stage
Pelvis manouvre->Lovsett
Mariceau Smellie Veit manouvre
Propped up dorsal position, bed needs to be able to allow lithotomy
Need experienced Obs/Anesthetist/Pediatrician
Arms normally crossed on chest
Legs delivered--> hand down, then occiput--> hands in mouth, forceps?
Delivered face to perineum
Mouth/nose cleared of mucus
At time of crowning->?episiotomy
3. Third stage
Placenta delivered normally
Syntometrine given when delivery of head as +risk of PPH

10

Counselling about breech risks

1. Due to no moulding, unable to determine if baby's head is too big
2. 1 in 20 risk of neonatal death during vaginal birth
3. Cord prolapse also more common
4. Term breech trial in Lancet 2000 showed 3 X mortality/morbidity with breech
5. Most will be born safely, many will die/brain damage.
6. If home birth, worse outcomes.
7. If >4000g ++risk
8. If primi, Xreassurance that she has delivered baby
9. Options are C section or ECV
10. 40% chance of reverting to cephalic with ECV, small risk to baby and cord->may need C section
11. Possible will change position any time up until labour, less likely if frank breech.

11

Explaining ECV

1. Should be performed at 36-37 weeks
2. Before this baby may turn spontaneously
3. Perform where facilities available for emergency C section
4. ContraI are: APH, HTN, uterine scar, multiples
5. Monitor fetus before and after
6. Tocolytic 30 mins before procedure
7. Direct damage to baby, cord entanglement and placental abruption
8. Gently dislodging buttocks from mother's pelvis and somersaulting into cephalic position
9. Rh -ve mothers should be given anti-D

12

Why is my baby in breech

1. Something obstructing lower segment
2. Uterine abnormalities
3. Some babies prefer position
4. +amniotic fluid
5. SGA

13

Brief explanation and booking of C section

1. Booked at 39 weeks, to avoid emergency if goes into labour
2. Regional anaesthesia
3. Will remain awake
4. One support person in the room
5. Can usually go home after 24 hours if well
6. 60-70% chance of VBAC in next pregnancy
7. Explain risks of procedure (2 in 10 000 risk of death)
8. Consent form
8. Bloods->FBC, G&H
9. Anesthetic review
10. Book in theatre

14

Management of mastitis

1. Can continue breastfeeding
2. Diflucloxacillin 10 days
3. Panadeine forte
4. Heat packs
5. Follow up

15

Cause of postpartum pyrexia

1. Urinary tract infection
2. Endometritis
3. Wound infection
4. Basal atelectasis and pneumonia
5. Mastitis
6. DVT
7. Incidental->another non-post partum related cause