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what is the lie of the fetes?
relationship of the fetes to the LONG AXIS of the uterus
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what are the 2 abnormal lies?
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where is the head felt in oblique lie?
one iliac fossa
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where is head felt in transverse lie?
flank
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when is abnormal lie more common?
- earlier in pregnancy
- before term it is normal
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what are the causes of abnormal lie?
- 1. circumstances that allow more room to turn: eg polyhydramnios, high parity (more lax uterus) - unstable lie
- 2. conditions that prevent turning: eg fettle and uterine abnormalities eg fibroids, twin pregnancies
- 3. conditions that prevent engagement: eg placenta praevia, pelvic tumours, uterine deformities
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what are the complications of abnormal lie?
- 1. labour cannot deliver fetes if head or breech cannot enter pelvis
- 2. arm or umbilical cord may PROLAPSE when ROM
- 3. if neglected prolapse, get OBSTRUCTION and UTERINE RUPTURE
- so both mother and fetus are at risk
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what is the management of transverse or unstable lie before 37 weeks?
no action unless woman is in labour
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what is the management of transverse or unstable lie after 37 weeks?
- woman admitted in case ROM
- ultrasound to exlude causes: polyhydramnios, placenta praevia
- NOT ECV as fetes usually turns back
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if after 37 weeks, abnormal lie when can you discharge a woman?
if spontaneous version occurs and PERSISTS for >48 hours
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what usually happens to a persistently abnormal lie by 41 weeks
usually stabilises as long as no pelvic obstruction
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if at 41 weeks there is still abnormal lie or woman is in labour what is to be done?
- 1. deliver by CS
- 2. expert hands ECV and then amniotomy = stabilising induction
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what does presentation mean?
part of the fetes that occupies the lower segment of the uterus or pelvis
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what proportion of 28 weeks are breech?
1/5
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what proportion of term babies are breech?
3%
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why is breech more common in premature labour? and what %
- 25% of premature labour
- because breech happens earlier in pregnancy more
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what are the 3 types of breech and describe leg position, give %
- extended breech: 70%, both legs extended at the knee, flexed at hips
- flexed breech: 15%, both legs flexed at the knee
- footling breech: 15%, more common preterm. one of both feet present below the buttocks
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what are causes/association of breech?
- 1. previous breech presentation only in 8%
- 2. prevent movement: fettle or uterine abnormalities or twins
- 2. prevent engagement of head: placenta praevia, pelvic tumours, pelvic deformities
- fetal (congen abN), placental (praevia, cornual), uterine (bicornuate, septate)
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what is the common symptom in breech presentation at term?
upper abdominal discomfort as head ballotable at funds
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what Ix needs to be done if suspected breech?
- USS:
- confirm diagnosis,
- detect fetal abnormality, pelvic tumour or placenta praevia
- ensure prerequisite for ECV
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what are the complications of breech delivery?
- 1. higher perinatal long term morbidity and mortality
- 2. fetal abnormlities
- 3. cord prolapse as breech or feet do not 'fit' well in pelvis so more room for cord to prolapse
- 4. aftercoming head may get trapped - can die birth asphyxia
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what are 3 options for women with breech presentation at term?
- 1. ECV
- 2. LSCS
- 3. vaginal BREECH delivery
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when is ECV done in breech and which drug is needed?
- after 37 weeks
- tocolytic atosiban oxytocin receptor antagonist
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how is ECV done?
- breech is disengaged from pelvis, pushed upwards to the side
- rotate in form of forward somersault/Users/kavinashah/Documents/Medicine year 4/O&G Flashcards/still to do/breech.txt
- under US guidance
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what needs to be done straight after ECV? 2 things
- 1. CTG
- 2. anti-D to Rh -ve women
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what are the risks of ECV?
- 1. fetal damage: minimal
- 2. placental abruption
- 3. uterine rupture
- 4. emergency C-section, so have to do ECV in hospital
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what factors affect the success of ECV?
- 1. nulliparous
- 2. caucasions
- 3. if breech is engaged
- 4. head not easily palpable
- 5. uterine tone high
- 6. obese women
- 7. reduced liquor volume
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what are the absolute CI to ECV?
- Multiple pregnancy
- Significant APH, placenta praevia
- Severe fetal abnormalities
- Hyperextended head
- SROM
- Other indications for CS
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what are the relative CI to ECV?
- Previous Caessarian section
- Severe Hypertension
- IUGR
- Oligohydramnios
- Previous myomectomy
- Marked maternal obesity
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what is the success rate of ECV?
30-80%
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if ECV didn't work or was CI or breech was missed what is the safest method of delivery for term breech?
Caesarean section
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what is the advantage of C/S in breech?
- reduces neonatal mortality
- reduces short term morbidity
- (but does not affect long term outcomes)
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what proportion of attempted vaginal breech deliveries end in emergency CS? why worse?
- > 1/3
- this is worse than elective procedure
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what are the 4 requisites for vaginal breech birth?
- 1. frank or complete breech aka extended
- 2. not a hyperextended head
- 3. no evidence of fetopelvic disproportion
- 4. baby < 4kg
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what factors of the fetes makes vaginal breech delivery more risky?
- 1. large fetus > 4.0kg
- 2. evidence of fettle compromise
- 3. extended head
- 4. footling legs
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if there is slow cervical dilatation or poor descent of breech, what should be done?
- caesarean
- DO NOT AUGMENT WITH OXYTOCIN
- only push when buttocks are visible
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what are the steps of breech delivery?
- make sure CTG and epidural analgesia recommended
- 1. once buttocks distend the perineum, EPISIOTOMY made
- 2. fetes delivers with maternal effort as far as the UMBILICUS and should not be touched
- 3. legs can be flexed out of the vagina, whilst the back is kept anterior. Pinard's manoeuvre is pressure to popliteal fossa
- 4. once scapula is visible, the anterior then posterior arms are hooked down by a finger over the shoulder sweeping it across the chest
- 5. if arms cannot be reached because they are extended above the neck, then LOVSET'S procedure is required - rotate body and down traction so shoulder and arms come out
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what manoeuvre is used to deliver the legs and feet?
Pinard's
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what manoeuvre is used to deliver the shoulder and arms?
Lovset's
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what manoeuvre is used to deliver the head?
Mauriceau-Smellie-Veit
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if this fails what is used?
forceps, need assistant to hold legs up
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