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Management of Breech Presentation (GTG 20B - Mar 2017) - Coggle Diagram
Management of Breech Presentation
(GTG 20B - Mar 2017)
Epidemiology
Breech presentation complicates
3-4% of term deliveries
Undetected breech presentations at term
: 20-32.5% of all breech presentations
Breech presentation at term undiagnosed untill labour
: 25%
Commoner in nulliparous women and preterm deliveries
Associated with uterine and congenital abnormalities
Risk of perinatal mortality for breech
Caesarean section after 39 weeks: 0.5/1000 (0.05%)
Vaginal breech: 2/1000 (0.2%)
Planned cephalic: 1/1000 (0.1%)
General Advice
Offer ECV unless absolute contraindication
Advise on risks and benefits of ECV and implications for mode of delivery
Counsel on risks and benefits of planned vaginal breech delivery versus planned Caesarean section
Counselling
Mode of Delivery
Planned Caesarean section has a 2-5 fold reduction in perinatal mortality compared to vaginal breech
Avoidance of stillbirth after 39 weeks
Avoidance of intrapartum risks
Avoidance of risks of vaginal breech
Risks of planned vaginal breech
Low Apgar scores
Cord prolapse
Serious short-term complications
Labour complications including need for Caesarean section in
45% of women
Planned Caesarean section
Small increase in immediate complications for the mother compared with planned vaginal breech delivery
Risk highest with emergency Caesarean section, required in approximately 40% of women planning vaginal breech delivery
Increases risks of complications in future pregnancies (including
VBAC 0.5%
), risk of complications at repeat Caesarean section, and risk of
abnormally invasive placenta
(increases from
0.31% with 1 previous section to 2.33% with 4 previous sections
)
Small increase in risk of stillbirth for subsequent babies:
Risk of delivery-related perinatal mortality after 1 section is 12.9/10,000
, most attributable to uterine rupture
Factors influencing Safety of Vaginal Breech
Higher risk associated with
:
Hyper-extended neck on ultrasound
High estimated fetal weight >3.8kg
Low estimated fetal weight <10th centile
Footling presentation
Antenatal fetal compromise
Existing indication for Caesarean section
Presence of experienced personnel; advise delivery in a hospital with facilities for immediate Caesarean section
Presenting in labour
Women near or in active second stage of labour should not be routinely offered Caesarean section
If time permits, position of the fetal neck and legs, and fetal weight should be estimated using ultrasound
Intrapartum Management
Induction of labour
: Not usually recommended
Augmentation
: Consider augmentation of slow progress with oxytocinin only if contraction frequency is low (<4 in 10) in the presence of epidural analgesia. Should usually be avoided as adequate progress may be the best evidence for adequate fetopelvic proportions.
Epidural analgesia
: Likely to increase risk of intervention. Known to increase risk of assisted vaginal delivery with cephalic presentation. Vaginal breech is usually easier if a mother is able to push effectively and an epidural may interfere with this.
Fetal monitoring
: Continuous EFM may lead to improved neonatal outcomes. Cord compression as the head enters the pelvis is better tolerated by a non-hypoxic fetus, and good fetal tone enables easier delivery. If abnormal, advise delivery by Caesarean section.
First stage
: Only ARM if indicated to reduce risk of cord compression. Consider caesarean section if slow progress.
Second stage:
Allow passive descent to the perineum prior to active pushing. If not visible within 2 hours of passive second stage, recommend Caesarean section.
Position of delivery
: Either a semirecumbent or all-fours position may be adopted. Recourse to semirecumbent may be necessary if manoeuvres are required.
Active Second Stage
Assistance without traction
is required if there is delay or poor fetal condition
Encourage maternal effort only when the breech is visible
Once buttocks have passed the perineum, cord compression is common.
Avoid traction ("hands-off" approach)
but intervene if progress not made once umbilicus has delivered or there is poor tone, extended arms, or an extended neck.
Tactile simulation
may result in reflex extension of the arms or head
Avoid fetal trauma
: Grasp the fetus around the pelvic girdle (not soft tissues), and never hyperextend the neck
Undertake selective rather than routine episiotomy
When to intervene
Poor fetal condition
Delay of >5minutes from delivery of buttocks to the head
Delay of >3 minutes from umbilicus to the head
Lack of tone or colour
Delay due to extended arms or neck
Semirecumbent position
Keep the back anterior
Loveset's manoeure for the arms
Mauriceau-Smellie-Veit or forceps for the aftercoming head
AVOID Burns-Marshall
technique due to overextension of the neck
Bracht manoeuvre
: Following delivery to the umbilicus, the body is grasped in both hands keeping legs flexed against abdomen, and without traction is brought up against the symphysis pubis, accompanied by suprapubic pressure
Preterm Breech Deliveries
Routine Caesarean section in spontaneous preterm labour not recommended
Caesarean section at the threshold of viability (22-25+6) not recommended
Risk of neonatal mortality 3.8% (Caesarean section) vs 11.5% (vaginal delivery)
Elective Caesarean section recommended
if women with maternal/fetal compromise (pre-eclampsia, fetal growth restriction, antepartum haemorrhage)
Management of head entrapment
Lateral cervical incisions at 2, 6, 10 o'clock positions
J-shape or inverted T incisions at Caesarean section
Risk
: Delivery of the body through an incompletely dilated cervix (14% of vaginal deliveries)
Twin Pregnancy with Breech
Presenting twin breech
: Advise planned Caesarean section
Presenting twin breech (spontaneous)
: Routine emergency Caesarean section not recommended. Individualise mode of delivery based on cervical dilatation, station of presenting part, type of breech, fetal wellbeing, and availability of skills personnel.
Second twin breech (40% of twin pregnancies)
: Routine Caesarean section not recommended in either term or preterm deliveries.