what is the lie of the fetes?
relationship of the fetes to the LONG AXIS of the uterus
what are the 2 abnormal lies?
where is the head felt in oblique lie?
one iliac fossa
where is head felt in transverse lie?
when is abnormal lie more common?
- earlier in pregnancy
- before term it is normal
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
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
what is the management of transverse or unstable lie before 37 weeks?
no action unless woman is in labour
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
if after 37 weeks, abnormal lie when can you discharge a woman?
if spontaneous version occurs and PERSISTS for >48 hours
what usually happens to a persistently abnormal lie by 41 weeks
usually stabilises as long as no pelvic obstruction
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
what does presentation mean?
part of the fetes that occupies the lower segment of the uterus or pelvis
what proportion of 28 weeks are breech?
what proportion of term babies are breech?
why is breech more common in premature labour? and what %
- 25% of premature labour
- because breech happens earlier in pregnancy more
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
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)
what is the common symptom in breech presentation at term?
upper abdominal discomfort as head ballotable at funds
what Ix needs to be done if suspected breech?
- confirm diagnosis,
- detect fetal abnormality, pelvic tumour or placenta praevia
- ensure prerequisite for ECV
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
what are 3 options for women with breech presentation at term?
- 1. ECV
- 2. LSCS
- 3. vaginal BREECH delivery
when is ECV done in breech and which drug is needed?
- after 37 weeks
- tocolytic atosiban oxytocin receptor antagonist
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
what needs to be done straight after ECV? 2 things
- 1. CTG
- 2. anti-D to Rh -ve women
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
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
what are the absolute CI to ECV?
- Multiple pregnancy
- Significant APH, placenta praevia
- Severe fetal abnormalities
- Hyperextended head
- Other indications for CS
what are the relative CI to ECV?
- Previous Caessarian section
- Severe Hypertension
- Previous myomectomy
- Marked maternal obesity
what is the success rate of ECV?
if ECV didn't work or was CI or breech was missed what is the safest method of delivery for term breech?
what is the advantage of C/S in breech?
- reduces neonatal mortality
- reduces short term morbidity
- (but does not affect long term outcomes)
what proportion of attempted vaginal breech deliveries end in emergency CS? why worse?
- > 1/3
- this is worse than elective procedure
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
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
if there is slow cervical dilatation or poor descent of breech, what should be done?
- DO NOT AUGMENT WITH OXYTOCIN
- only push when buttocks are visible
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
what manoeuvre is used to deliver the legs and feet?
what manoeuvre is used to deliver the shoulder and arms?
what manoeuvre is used to deliver the head?
if this fails what is used?
forceps, need assistant to hold legs up