Obstetrics Marrow Pg 545-554 (Labor & Puerperium)
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What is the most common type of breech presentation overall?

  • Flexed/Complete breech
  • Footling breech
  • Knee presentation
  • Frank breech (correct)

    • The incidence of breech presentation increases as the gestation period progresses.

    False

    What is the common cause of recurrent breech presentations?

    Uterine malformation

    At 34 weeks of gestation, the incidence of breech presentation is approximately _____%.

    <p>5</p> Signup and view all the answers

    Match the following types of breech presentations with their features:

    <p>Flexed/Complete breech = Hips &amp; Knees flexed Frank breech = Hips flexed + knees extended Knee presentation = Hips extended + Knees flexed Footling breech = Hips &amp; Knees extended</p> Signup and view all the answers

    What is the most common cause of incomplete forward rotation during childbirth?

    <p>Android pelvis</p> Signup and view all the answers

    A caesarean section is the best management for an anthropoid pelvis.

    <p>False</p> Signup and view all the answers

    What does ROP stand for in the context of fetal head position?

    <p>Right Occipito Posterior</p> Signup and view all the answers

    The ____ is a bony landmark within the pelvis that is significant in childbirth.

    <p>ischial spine</p> Signup and view all the answers

    Match the following management options with their appropriate pelvic types:

    <p>Caesarean section = Android pelvis Vacuum delivery = Anthropoid pelvis Manual Rotation = Other pelvis types Forceps delivery = Other pelvis types</p> Signup and view all the answers

    What is the engaging diameter during shoulder delivery?

    <p>13 cm</p> Signup and view all the answers

    The anterior shoulder rotates posteriorly by 1/8th of a circle during childbirth.

    <p>False</p> Signup and view all the answers

    Name one method used if the shoulder is not aligned along the anterior-posterior diameter.

    <p>Method a, Method b, or Method c</p> Signup and view all the answers

    The Burns-Marshall technique is applied when the _____ is visible.

    <p>nape of the neck</p> Signup and view all the answers

    What happens during spontaneous delivery if the shoulder is not aligned correctly?

    <p>Spontaneous delivery may occur.</p> Signup and view all the answers

    Match the following methods with their descriptions:

    <p>Method a = Spontaneous delivery with shoulder rotation Method b = Using fingers to rotate the baby's shoulders Method c = Reaching the cubital fossa for delivery Burns-Marshall Technique = Allowing the baby to hang on its own weight</p> Signup and view all the answers

    The baby's head is the first part to be delivered in a breech presentation.

    <p>False</p> Signup and view all the answers

    What assists in the flexion of the baby's neck during the Burns-Marshall technique?

    <p>Suprapubic pressure</p> Signup and view all the answers

    Which of the following is an absolute indication for a Caesarean section?

    <p>Post-term or baby weight &gt; 4kgs</p> Signup and view all the answers

    One of the prerequisites for assisted breech delivery is that the baby must weigh less than 5 kgs.

    <p>False</p> Signup and view all the answers

    Name one contraindication for assisted breech delivery.

    <p>Induction of labor</p> Signup and view all the answers

    The engaging diameter for a vaginal delivery in breech presentation is the __________ diameter.

    <p>bitrochanteric</p> Signup and view all the answers

    Match the following terms with their descriptions:

    <p>CPD = Cephalo-pelvic disproportion LSA = Left sacroanterior position ECV = External cephalic version IV fluids = Intravenous fluids administration</p> Signup and view all the answers

    Which maneuver is specifically used for frank breech delivery?

    <p>Pinard maneuver</p> Signup and view all the answers

    In breech presentations, the sacrum lies behind the pubic symphysis.

    <p>False</p> Signup and view all the answers

    What happens during the engagement phase of right sacro anterior (RSA) breech delivery?

    <p>The buttocks engage in right oblique diameter.</p> Signup and view all the answers

    The ______ technique is employed to prevent cord exposure during breech delivery.

    <p>Savage</p> Signup and view all the answers

    Match the following maneuvers with their purpose in breech deliveries:

    <p>Groin traction = Complete breech delivery Pinard maneuver = Frank breech delivery Savage technique = Prevent cord exposure Episiotomy = Facilitate delivery</p> Signup and view all the answers

    What is the most common presentation in breech deliveries?

    <p>Dorso-anterior</p> Signup and view all the answers

    Cord prolapse is less likely in footling breech presentations than in transverse lie.

    <p>False</p> Signup and view all the answers

    What should be ruled out when assessing a breech presentation using ultrasound?

    <p>Gross congenital anomalies and hyperextension of the neck.</p> Signup and view all the answers

    An ECV is indicated in breech presentation at term and when there are no __________ for the procedure.

    <p>contraindications</p> Signup and view all the answers

    Match the terms related to breech management with the appropriate descriptions:

    <p>ECV = External Cephalic Version OPD = Outpatient Department C-Section = Cesarean Section Dorso-anterior = Breech presentation type</p> Signup and view all the answers

    What is the maximum fetal weight for which ECV is considered?

    <p>4 kg</p> Signup and view all the answers

    Emergency C-section may be performed in cases of fetal distress after attempting other procedures.

    <p>True</p> Signup and view all the answers

    At what gestational age should ECV be performed?

    <p>At greater than 37 weeks.</p> Signup and view all the answers

    What is the primary management strategy for a hand prolapse during labor?

    <p>Cesarean section</p> Signup and view all the answers

    Multiple loops of umbilical cord around the neck can be a risk factor for face presentation.

    <p>True</p> Signup and view all the answers

    What is the denominator used in face presentations?

    <p>Mentum</p> Signup and view all the answers

    In cases where cesarean section is indicated due to a transverse lie, it is due to a lack of _____ during labor.

    <p>rotation</p> Signup and view all the answers

    Match the following features with the corresponding presentations:

    <p>Hand Prolapse = Management is cesarean section Face Presentation = Longitudinal lie with face as presenting part Brow Presentation = Abnormal flexion with brow presenting Transverse Lie = Cannot be delivered vaginally if labor is obstructed</p> Signup and view all the answers

    What is the most common complication associated with an anthropoid pelvis during delivery?

    <p>Complete perineal tear</p> Signup and view all the answers

    Transverse lie is most commonly caused by the condition known as placenta previa at term.

    <p>True</p> Signup and view all the answers

    What needs to be confirmed via USG before performing an external cephalic version?

    <p>Lie of baby, adequate liquor, singleton pregnancy, absence of gross anomalies</p> Signup and view all the answers

    The _____ is the bony landmark associated with the shoulder in transverse lie.

    <p>acromion process</p> Signup and view all the answers

    Match the following features with their appropriate definitions:

    <p>Dorso-anterior = Most common position in transverse lie Spontaneous rotation = Usually occurs after 34 weeks of gestation C-section = Management for deep sacral arrest Fundal grip = Examination technique for lie assessment</p> Signup and view all the answers

    What is the engaging diameter for mento-posterior presentation?

    <p>9.5 cm</p> Signup and view all the answers

    In mento-anterior presentation, the chin faces anteriorly.

    <p>True</p> Signup and view all the answers

    What is the denominator in brow presentation?

    <p>Frontal bone</p> Signup and view all the answers

    In cases of mento-posterior face presentation, the management option is a __________.

    <p>C-section</p> Signup and view all the answers

    Which of the following presentations requires a wait and watch approach during early labor?

    <p>All of the above</p> Signup and view all the answers

    Match the presentation with its engaging diameter:

    <p>Mento-posterior = 9.5 cm Brow = 14 cm Mento-anterior = 9.5 cm Mento-transverse = Not specified</p> Signup and view all the answers

    Mento-transverse presentation requires a C-section.

    <p>True</p> Signup and view all the answers

    What is the management approach for a brow presentation?

    <p>C-section</p> Signup and view all the answers

    What is the primary medication used before an External Cephalic Version (ECV) procedure to relax the uterus?

    <p>Terbutaline</p> Signup and view all the answers

    Anaesthesia is required for an External Cephalic Version procedure.

    <p>False</p> Signup and view all the answers

    At what gestational age can an External Cephalic Version procedure be performed?

    <p>36 to 37 weeks</p> Signup and view all the answers

    Anti-D injection is administered for Rh-____ patients.

    <p>negative</p> Signup and view all the answers

    Match the following terms to their definitions concerning ECV:

    <p>Tocolytic = Medications used to relax the uterus Singleton pregnancy = Pregnancy with only one fetus Oligohydramnios = Insufficient amniotic fluid Ruptured membranes = Membranes surrounding the fetus have burst</p> Signup and view all the answers

    Which of the following is an absolute contraindication for performing an ECV?

    <p>Ruptured membranes</p> Signup and view all the answers

    Multiple attempts are not allowed for an External Cephalic Version procedure.

    <p>False</p> Signup and view all the answers

    What is the first step if the first ECV attempt is unsuccessful?

    <p>Retry on another day</p> Signup and view all the answers

    Continuous ______ monitoring is performed during the ECV to ensure fetal well-being.

    <p>fetal</p> Signup and view all the answers

    If the second ECV attempt is successful, what must be done next?

    <p>Induce labor with an oxytocin drip</p> Signup and view all the answers

    Study Notes

    Engaging Diameter

    • The bisacromial diameter, measuring 13 cm, is the engaging diameter during shoulder delivery
    • The anterior shoulder touches the levator ani muscle during delivery
    • The anterior shoulder rotates anteriorly by 1/8th of a circle

    Shoulder Delivery Methods

    • If the shoulder is not aligned along the anterior-posterior (A-P) diameter of the pelvis, several methods can be used to assist delivery
    • Method a (spontaneous delivery) involves holding the baby's back and turning the shoulders to align with the A-P diameter, hoping for a spontaneous delivery
    • If spontaneous delivery fails in Method a, Method b (Lovset's maneuver) is used to rotate the baby's shoulders so the posterior shoulder moves to the anterior position, allowing for spontaneous delivery of the arm and shoulder
    • If Method b fails, Method c involves reaching the cubital fossa with fingers to deliver the arm and posterior shoulder

    After Coming Head of Breech

    • The head is the last part to be delivered in a breech presentation
    • The head is delivered by flexion

    Burns-Marshall Technique

    • This technique is used when the nape of the neck is visible
    • The baby is allowed to hang on its own weight to facilitate neck flexion
    • Suprapubic pressure is applied to aid in neck flexion
    • The baby's feet turn towards the mother's abdomen
    • The head is then delivered

    Features, Causes, and Types of Breech

    • Breech presentation is the most common malpresentation during labor
    • Breech presentation occurs in a longitudinal lie
    • The incidence of breech presentation is high at 28 weeks (25-28%) but decreases to 3-4% at term
    • The most common cause of overall breech presentation is prematurity
    • Recurrent breech presentations can be caused by uterine malformations
    • Breech presentations are classified into four types: complete breech, frank breech, knee presentation, and footling breech

    Complete Breech

    • Hips and knees are flexed
    • Heel, anal opening, ischial tuberisties, and external genitalia (in males) are felt on pelvic examination
    • Complete breech is the most common type in multigravida pregnancies

    Frank Breech

    • Hips are flexed, knees are extended
    • Anal opening, ischial tuberisties, and external genitalia (in males) are felt on pelvic examination
    • Frank breech is the most common type overall and in primigravida pregnancies

    Knee Presentation

    • Hips are extended, knees are flexed

    Footling Breech

    • Hips and knees are extended

    Bitrochanteric Diameter

    • The bitrochanteric diameter is 10 cm and covers the cervix when fully dilated (10 cm)
    • Footling breech and knee presentation carry a higher risk of complications

    Incomplete Forward Rotation

    • ROP refers to the rotation of the fetal head
    • ROT is another point of reference for fetal head position
    • Incomplete forward rotation indicates the fetal head has not rotated completely
    • Incomplete forward rotation often occurs at the level of the ischial spines
    • Incomplete forward rotation is most commonly associated with an android pelvis

    Causes of Incomplete Forward Rotation

    • Android pelvis is the most common cause
    • Large fetal size can increase the chance of incomplete forward rotation
    • Low liquor (reduced amniotic fluid) can contribute to incomplete forward rotation
    • Deep transverse arrest occurs when the fetal head is stuck in the occipito-transverse position in the pelvis despite strong uterine contractions

    Management of Incomplete Forward Rotation

    • Caesarean section is the preferred management for an android pelvis
    • Other pelvic types may be managed with vacuum delivery, manual rotation, or forceps delivery

    Posterior Rotation

    • Posterior rotation is most common in anthropoid pelves
    • The anterior-posterior (AP) diameter is much larger than the transverse diameter in an anthropoid pelvis
    • Forceps delivery is often outdated for posterior rotation

    Management of Breech Presentation

    • Transverse lie, footling breech, and knee presentation are most likely to lead to cord prolapse
    • Dorso-anterior is the most common presentation in breech
    • Ultrasound (USG) is crucial to confirm the diagnosis, assess the type of breech, rule out gross congenital anomalies and hyperextension of the neck, estimate fetal weight, and assess pre-requisites for external cephalic version (ECV)
    • ECV is a procedure to rotate the baby from breech presentation to cephalic presentation at term
    • ECV is performed in an outpatient department (OPD) at >37 weeks
    • Contraindications for ECV include:
      • Gross congenital anomalies
      • Hyperextension of the neck
      • Fetal weight < 4kg
      • Pre-existing conditions like placenta previa, previous C-section, or pregnancy-induced hypertension
      • Breech score ≤ 3

    ECV Decision-Making Flowchart

    • ECV is attempted first in OPD at >37 weeks
    • If successful, the patient is sent home and waits for spontaneous labor
    • If unsuccessful, another attempt is made
    • If the second attempt is successful, labor is induced with oxytocin
    • If the second attempt fails, an elective cesarean section is recommended at 39 weeks
    • If fetal distress arises during ECV, procedures are stopped, and an emergency C-section is performed

    Modes of Delivery in Breech Presentation

    • Cesarean section
    • Assisted breech delivery

    Caesarean Section Indications for Breech Presentation

    • Footling, knee, or stargazer breech
    • Preterm breech and weight < 1.5kg
    • Post-term or baby weight > 4kgs
    • First twin being breech
    • Previous C-section
    • Pregnancy-induced hypertension or placenta previa
    • Breech score ≤ 3
    • Protracted active phase (delay in 1st or 2nd stage)

    Relative Indication for Caesarean Section in Breech Presentation

    • Primigravida with breech

    Assisted Breech Delivery

    • Vaginal delivery attempted in a breech presentation
    • Sacrum is the denominator
    • Bitrochanteric diameter (10 cm) is the engaging diameter
    • Left sacroanterior (LSA) is the most common position

    Contraindications for Assisted Breech Delivery

    • Induction of labor
    • Augmentation of labor
    • Abnormalities can lead to a rupture of the membrane and cord prolapse

    Pre-requisites for Assisted Breech Delivery

    • Availability of facilities for emergency cesarean section
    • Supervision by a senior doctor
    • Baby weight <4kg
    • Patient kept nil oral and given IV fluids
    • Continuous fetal heart rate monitoring by cardiotocography (CTG)

    Complication of Assisted Breech Delivery

    • The baby's head can get stuck as it is the last part to be delivered
    • Fetal hypoxic injury or intracranial haemorrhage is possible

    Mechanism of Breech Delivery

    • In right sacroanterior (RSA) position:
      • Buttocks engage in the right oblique diameter
      • Anterior buttock touches the levator ani
      • Buttocks descend the perineum by 1/8th of a circle (episiotomy may be given)
      • Buttocks clear the perineum
    • The sacrum (denominator in breech) does not lie behind the pubic symphysis

    Maneuvers to Deliver Buttocks

    • If spontaneous delivery does not occur:
      • Groin traction is used in complete breech
      • Pinard maneuver is used in frank breech to unlock the popliteal fossa

    Savage Technique

    • This technique is used to prevent cord exposure
    • A warm, moist towel is wrapped around the baby's lower body before shoulder delivery
    • Touching the cord can cause vasospasm and fetal distress

    Active Space --- Outcomes:

    • Anthropoid pelvis is the most common pelvic type
    • Face-to-pubes delivery is possible with vaginal delivery when the face is towards the pubic symphysis
    • Occiput-to-sacral promontory delivery is common and can lead to a complete perineal tear, warranting an episiotomy
    • Deep sacral arrest occurs when the baby cannot be delivered and remains in that position for >30 mins, requiring a C-section

    Transverse Lie

    • Lie: Transverse
    • Presentation: Shoulder
    • Denominator: Acromion process
    • Position: Dorso-anterior (most common) > Dorso-posterior
    • Most common outcome: Rotation during pregnancy (>34 weeks) to cephalic or breech

    Causes of Transverse Lie

    • Most common cause is prematurity
    • At term: Placenta previa
    • Examination findings:
      • Height of uterus < period of gestation
      • Fundal grip and deep pelvic grip: empty
    • Complication: Highest chance of cord prolapse

    External Cephalic Version (ECV)

    • Indications:
      • Transverse lie
      • Breech presentation
    • Preliminary Investigation: USG to confirm:
      • Lie of baby
      • Adequate liquor
      • Singleton pregnancy
      • Absence of gross anomalies

    ECV Procedure

    • Performed at an outpatient department (OPD)
    • Baby is rotated to a cephalic presentation
    • Anaesthesia is not required
    • Terbutaline 0.25mg s/c is given 30 minutes before the procedure to relax the uterus
    • Anti-D injection given to Rh-negative mothers
    • Induction of labor is not routinely indicated
    • Continuous fetal heart rate monitoring is performed
    • If fetal distress arises, the procedure is stopped
    • Immediate C-section performed if fetal distress arises

    Pre-requisites for ECV

    • Gestational period: 36-37 weeks
    • Adequate liquor
    • Intact membranes
    • Early labor (latent phase)
    • Singleton pregnancy
    • Normal fetal heart rate
    • No contraindication for vaginal delivery

    Relative Contraindications for ECV

    • PIH (Pregnancy-induced hypertension)
    • Heart disease in mother
    • IUGR (Intrauterine Growth Restriction)
    • Previous LSCS (Lower Segment Caesarean Section)

    Absolute Contraindications for ECV

    • Oligohydramnios (Insufficient amniotic fluid)
    • Ruptured membranes
    • Active phase of labor
    • Twin/multifetal pregnancy
    • Abnormal fetal heart rate on CTG
    • Placenta previa or contracted pelvis
    • Uterine/Fetal gross anomalies

    ECV Attempts

    • The procedure may require multiple attempts
    • Successful in 1st attempt: Wait for spontaneous labor
    • Fails in 1st attempt: Retry on another day
    • Successful in 2nd attempt: Induce labor with oxytocin drip
    • Fails in 2nd attempt: Elective caesarean at 39 weeks

    Hand Prolapse/Neglected Shoulder Presentation

    • Indications for Cesarean Section:
      • ECV failed twice
      • ECV contraindicated
      • Transverse lie in active labor

    Pathophysiology of Hand Prolapse/Neglected Shoulder Presentation

    • Transverse lie and vaginal delivery trial to rotate the baby
    • Hand of baby pulled to facilitate rotation
    • Hand prolapse
    • Obstructed labor (Bandl's ring)

    Management of Hand Prolapse/Neglected Shoulder Presentation

    • Cesarean section
    • No role for destructive procedures (decapitation, evisceration)

    Face Presentation

    • Lie: Longitudinal
    • Presentation: Cephalic
    • Presenting part: Face
    • Abnormal attitude: Complete extension
    • Denominator: Mentum

    Risk Factors for Face Presentation

    • Anencephaly (only face is normal)
    • Factors preventing flexion of baby's head:
      • Tight loops of umbilical cord around the neck
      • Anterior neck mass
    • Multiparous women
    • Platypelloid pelvis

    Other Important Information About Face Presentation

    • No mechanism of labor
    • Only C-section is possible
    • Mento-posterior face presentation is a contraindication for vaginal delivery

    Mento-Posterior Presentation

    • Chin faces posteriorly
    • Left mento-anterior is a specific position
    • Engaging diameter: Suboccipito-bregmatic (9.5 cm)
    • Management: Vaginal delivery (the head is delivered by flexion)
    • No mechanism of labor, only C-section is possible
    • Wait and watch in early labor: Spontaneous rotation to mento-anterior may occur

    Mento-Anterior Presentation

    • Chin faces anteriorly
    • Management: Vaginal delivery (the head is delivered by flexion)
    • No mechanism of labor; only C-section possible
    • Wait and watch in early labor: Spontaneous rotation to mento-anterior may occur

    Mento-Transverse Presentation

    • Chin faces transversely
    • No mechanism of labor; only C-section possible
    • Wait and watch in early labor: Spontaneous rotation to mento-anterior may occur

    Brow Presentation

    • Occurs in partial extension of the head
    • Bony landmarks on pelvic examination:
      • Anterior fontanelle (diamond shaped)
      • Supraorbital ridges
    • Engaging diameter: Mento-vertical diameter (14 cm)
    • Denominator: Frontal bone
    • No mechanism of labor; only C-section possible
    • Wait and watch in early labor: Complete extension or flexion may occur

    Delivery by Flexion of Head

    • Cesarean section is mandatory in:
      • Transverse lie
      • Hand prolapse
      • Neglected shoulder
      • Mento-posterior face presentation
      • Brow presentation

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    Test your knowledge on breech presentations and childbirth management with this obstetrics quiz. Covering common causes, incidence rates, and techniques related to fetal positions, this quiz offers a comprehensive review of key concepts crucial for healthcare professionals. Perfect for medical students and practitioners looking to refresh their understanding.

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