Questions and Answers
What percentage of singleton deliveries typically experience breech presentation at term?
Which type of breech presentation is the most common and allows for vaginal delivery?
What characterizes an incomplete breech presentation?
What is a footling breech?
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Which of the following is true about a stargazing fetus?
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What percentage of breech presentations are classified as complete breech?
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Which of the following is considered a maternal risk factor for breech presentation?
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Which condition is commonly associated with placental risk factors for breech presentation?
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What is a fetal condition that could increase the risk of breech presentation?
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What is the primary method used to confirm a breech presentation?
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What does Leopold's Maneuver LM4 aim to determine?
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Which imaging technique is used to assess the bony pelvis prior to vaginal delivery?
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During a vaginal examination, which finding would indicate a frank breech presentation?
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Which statement about sonography's role in breech presentation assessment is accurate?
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Which aspect of vertex presentation is typically assessed through vaginal examination?
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What is a potential complication for the mother during delivery related to infection?
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Which complication is most likely to occur due to a delay in delivery?
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Which factor should influence the decision on the mode of delivery?
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What is a possible perinatal complication resulting from a difficult delivery?
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Which of the following may be an immediate risk associated with umbilical cord prolapse during delivery?
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What factor is NOT considered when determining the mode of delivery?
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According to studies, what is the general outcome preference for term breech deliveries?
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Which factor influences the decision for mode of delivery in the case of term fetuses?
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What maternal factor could lead to a cesarean delivery for a breech fetus?
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Which fetal condition could increase the likelihood of opting for a cesarean delivery when presenting as a breech?
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Which staff member is essential for the delivery of a breech fetus via cesarean section?
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What is a common maternal risk factor for cesarean delivery in breech presentations?
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What defines spontaneous breech delivery?
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Which maneuver involves rotation of the fetal body to assist in delivery?
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What is the primary focus of the Mauriceau Maneuver?
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What is involved in the Piper Forceps technique?
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What is a critical aspect of the Modified Prague Maneuver?
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What does Loveset’s maneuver specifically require during delivery?
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What is the primary action performed during a total breech extraction?
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Which technique involves holding both feet of the fetus to assist its delivery?
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What does the Burns Marshall Method involve during delivery?
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What is moxibustion primarily used for in obstetrics?
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What does moderate traction during frank breech delivery facilitate?
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In what situation is an episiotomy typically performed during breech deliveries?
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What is the initial phase of Pinard's maneuver?
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Study Notes
Breech Presentations Overview
- Breech presentation occurs in approximately 3 to 5% of singleton deliveries at term.
- Characterized by fetal buttocks or legs entering the pelvis before the head.
- More common during early stages of pregnancy.
Types of Breech Presentations
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Frank Breech
- Represents 50-70% of breech presentations.
- Most common type and favorable for vaginal delivery.
- Fetal position: lower extremities flexed at the hips and extended at the knees, with feet near the head.
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Complete Breech
- Accounts for 5-10% of breech cases.
- Both hips flexed, with one or both knees also flexed; resembles a yoga pose.
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Incomplete Breech
- Constitutes 10-30% of cases.
- One or both hips extended, resulting in feet or knees positioned below the breech.
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Footling Breech: A type of incomplete breech with the following sub-types:
- Single Footling: One foot is lower than the fetal buttocks.
- Double Footling: Both feet or knees are lower than the fetal buttocks.
Additional Considerations
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Term Breech Fetuses
- Stargazing Fetus: Neck hyperextended (5%).
- Associated with a risk of cervical spinal cord injury during vaginal delivery, indicating a preference for cesarean delivery.
- Frequently presents in a transverse lie and is linked to congenital abnormalities.
Risk Factors for Breech Presentation
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Maternal Risk Factors:
- Multiparity: Increased likelihood with multiple previous pregnancies.
- Multifetal gestation: Presence of twins or more often increases the risk.
- Uterine or pelvic tumors and abnormalities can disrupt normal positioning of the fetus.
- Previous breech delivery raises chances of recurrence in subsequent pregnancies.
- Contracted pelvis: Narrow pelvic structure may limit fetal movement and positioning.
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Placental Risk Factors:
- Placenta previa: Condition where the placenta implants in the lower uterine segment, potentially covering or being near the internal cervical os, which may affect fetal positioning.
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Fetal Risk Factors:
- Hydrocephaly: Accumulation of cerebrospinal fluid in the brain may influence fetal posture.
- Anencephaly: A severe congenital condition leading to abnormal head shape and position.
- Prematurity: Preterm infants are more susceptible to abnormal presentations.
- Macrosomia: Fetal weight over 4 kg increases the likelihood of breech positioning due to size constraints.
Diagnosis of Breech Presentation
- Suspected through physical examination techniques, such as palpation of fetal position.
- Confirmation of breech presentation requires the use of ultrasound or advanced imaging techniques for accurate assessment.
Leopold's Maneuver
- LM1 assesses fetal position by feeling for a hard, round, and ballotable head.
- LM2 helps to identify the back and smaller parts of the fetus.
- LM3 identifies a movable breech at the pelvic inlet.
- LM4 checks for a firm breech beneath the symphysis pubis.
- Primarily applicable for cephalic presentations to determine fetal attitude (extension or flexion).
Vaginal Examination
- Internal examination differentiates between breech and cephalic presentations.
- Conducted only if sufficient cervical dilatation is present.
- Frank breech palpation involves the ischial tuberosity, sacrum, anus, and external genitalia, noting muscular resistance due to meconium.
- Cephalic examination focuses on fetal sutures and fontanels, indicating less yielding jaws.
Imaging Techniques
- Used to determine the type of breech presentation and assess neck extension for vaginal delivery safety.
- Sonography confirms breech type and the degree of neck flexion or extension.
- Frank breech is amenable to vaginal delivery; avoid emergency caesarean sections for non-viable anomalous fetuses.
- Imaging pelvimetry evaluates the bony pelvis before vaginal delivery.
- CT scans are preferred for their accuracy, low radiation exposure, and availability.
Maternal Complications
- Incision extension can occur during surgical interventions, increasing recovery complexity.
- Potential for vaginal and cervical wall lacerations, leading to longer healing times and complications.
- Deep perineal tears can arise, impacting postpartum recovery and sexual function.
- Increased risks for infections post-delivery necessitate vigilant medical care.
- Postpartum hemorrhage is a significant concern, commonly associated with uterine atony and can be compounded by anesthesia.
Perinatal Complications
- Fractures of the hand or extremities may occur during delivery, particularly in difficult births.
- Brachial plexus stretching can result in nerve damage, affecting arm movement and sensation in the infant.
- Spinal cord injuries, though rare, can lead to severe long-term disabilities or neurological deficits.
- Umbilical cord prolapse demands immediate attention as it poses a serious risk during delivery.
- Fetal head entrapment is a critical situation that can lead to urgent intervention requirements.
- Birth asphyxia generally results from delayed delivery, emphasizing the importance of timely interventions.
Decision Making in Delivery
- Delivery mode decisions should consider the health care provider's experience and the specific case at hand.
- Planned vaginal delivery for a term singleton breech fetus may be viable if guided by specific hospital protocols, indicating the importance of tailored care management.
Route of Delivery
- Delivery methods include Caesarean Section (CS) and vaginal delivery, with various factors influencing the choice.
Determining Factors for Delivery Method
- Pelvic dimensions: Assessing the size and shape of the pelvis can determine feasibility for vaginal delivery.
- Coexistent pregnancy complications: Conditions such as gestational diabetes or hypertension can affect delivery method decisions.
- Provider experience: The skill level and familiarity of the attending physician with specific delivery methods are crucial.
- Patient preference: Women’s choices regarding their preferred delivery method play a significant role.
- Hospital capabilities: Availability of resources and support systems at the hospital can influence delivery options.
- Gestational age: The timing of delivery, especially between term and preterm, affects risks and benefits of delivery methods.
Term Fetuses
- Studies show conflicting results about whether planned CS or vaginal delivery is superior for singleton breech presentations.
- Some research suggests favorable outcomes for vaginal delivery; however, planned CS may also have advantages.
- Notable studies include:
- Term Breech Trial: Examined presentation and mode of delivery.
- PREMODA Study: Involved 8,000 participants, adding to the evidence base.
- WHO Lille Breech Group: Included data from approximately 100,000 cases.
Preterm Fetuses
- No randomized controlled trials are available for preterm breech delivery.
- Evidence suggests that planned CS may provide a survival advantage for preterm fetuses.
- According to AOGC guidelines, vaginal delivery for breech presentations may be considered reasonable when estimated fetal weight exceeds 2,500 grams.
Maternal Factors Favoring Cesarean Delivery
- Lack of operator experience can lead to a higher likelihood of cesarean delivery.
- Patient requests for a cesarean section may influence the delivery method.
- Pelvic contraction or an unfavorable pelvic shape, assessed clinically or through pelvimetry, favors surgical intervention.
- A history of prior cesarean delivery increases the chances of opting for another cesarean.
Fetal Factors Favoring Cesarean Delivery
- Fetal weight exceeding 3800 to 4000 grams raises concerns for vaginal delivery.
- An apparently healthy preterm fetus in active labor or requiring indicated delivery may necessitate cesarean.
- Severe fetal growth restriction is a significant factor favoring cesarean section.
- Fetal anomalies incompatible with vaginal birth can prompt a cesarean delivery.
- Previous instances of perinatal death or neonatal birth trauma influence decision-making.
- Incomplete or footling breech presentations are associated with a higher cesarean rate.
- Hyperextended head positions in breech fetuses can complicate vaginal delivery, leading to cesarean preference.
Necessary Staff for Cesarean Delivery
- An obstetrician is essential for performing the cesarean delivery.
- Midwives, nurses, or interns assist in surgical procedures and care.
- A pediatrician is required for immediate neonatal care post-delivery.
- An anesthesiologist is necessary to manage anesthesia during the procedure.
Spontaneous Breech Delivery
- The fetus is delivered entirely without any external traction or manipulation, relying solely on natural mechanisms and support for the newborn.
Partial Breech Extraction
- Occurs when the fetus is delivered spontaneously up to the umbilicus, after which additional traction and assistance are required.
- Techniques include operator traction and maternal expulsive efforts.
Loveset’s Maneuvers
- Involves rotating the fetal body by 180 degrees to achieve a right sacrum transverse (RST) position after the first arm is delivered.
- The provider's hand extends over the right shoulder, sweeping the arm downward across the chest and out.
- If trunk rotation fails, grasp the feet and elevate them over the mother's inner thigh to aid delivery.
Maneuvers for Delivery of the Aftercoming Head
- Mauriceau Maneuver: Head flexion achieved through pressure on the maxilla by an assistant; the infant is positioned "back up."
- Modified Mauriceau-Smellie-Veit (MSV): Adaptation of the traditional Mauriceau technique.
- Modified Prague Maneuver: Used when the fetus’s back does not rotate to the symphysis; involves placing two fingers on the shoulders and using the other hand to draw the feet, positioning the baby "back down."
- Piper Forceps: Utilized to grasp the head after it has engaged; requires the head to be at the level of the pelvic bone for effective application.
Methods of Vaginal Delivery
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Total Breech Extraction:
- Entire body of fetus is extracted by the obstetrician.
- Episiotomy is performed.
- Typically done for the second twin.
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Incomplete or Complete Breech:
- A hand is introduced vaginally to grasp both fetal feet.
- Ankles are held with the second finger positioned between them.
- Gentle traction pulls the feet through the introitus and vulva simultaneously.
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Frank Breech:
- Moderate traction applied via fingers in each groin.
- A generous episiotomy aids in delivery.
- Once the breech is through the introitus, steps for partial breech extraction are followed.
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Pinard’s Maneuver:
- Extraction technique for frank breech involves fingers placed in groins.
- Hips and knees flexed to allow delivery from the vagina once the hips are out.
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Burns Marshall Method:
- The breech is allowed to 'hang' by its weight until the nape of the neck or 'hairline' becomes visible.
- Both feet are held while the fetus is pressed onto the maternal abdomen to deliver the fetal head.
External Cephalic Version (ECV)
- Manipulation of the fetus through the abdominal wall to achieve a cephalic presentation.
- Generally attempted before labor in women at or above 37 weeks' gestation.
Moxibustion
- Traditional Chinese medicine technique utilizing ground Artemisia vulgaris.
- Involves burning a moxa stick against the skin or indirectly heating an acupuncture needle.
- Aims to increase fetal movement and encourage spontaneous breech version.
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Description
Test your knowledge on the classification of breech presentations. Understand the characteristics of different types, including Frank and Complete breech, and their implications during delivery. This quiz will help reinforce your understanding of fetal positions at term.
