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ABNORMAL LIE Definitions: - lie of fetus describes relationship to long axis of the uterus 1) NORMAL - if it is lying longitudinal within

the uterus, the lie is longitudinal, and the presentation will be cephalic (head) or breech, either will be palpable at the pelvic inlet 2) ABNORMAL if neither is present, the fetus must be lying across the uterus with the head in one iliac fossa (oblique) or in the flank (transverse) - abnormal lie occurs in 1 in 200 births, but is more common earlier in pregnancy Aetiology: - preterm labour is more commonly complicated by an abnormal lie than labour at term 1) circumstances that allow more room to turn (e.g. polyhydramnios, multiparity [more lax uterus]) 2) conditions that prevent turning (fetal and uterine abnormalities, twin pregnancies) 3) conditions that prevent engagement (placenta praevia, pelvic tumours, uterine abnormalities [e.g. fibroids]) Complications: - if the head or breech cannot enter the pelvis, labour cannot deliver the fetus - arm or the umbilical cord may prolapse when the membranes rupture, and if neglected, the obstruction eventually causes uterine rupture (both fetus and mother are therefore at risk!) Management: <37 weeks : common, no action is required >37 weeks : admitted to hospital in case the membranes rupture - ultrasound scan to identify particular causes - external cephalic version is unjustified because fetus usually turns back - only if spontaneous version occurs and persists for >48h can patient be allowed home

- in the absence of pelvic obstruction, an abnormal lie will usually stabilize before 41 weeks, at this stage, the persistently abnormal lie is delivered by Caesarean, although ECV and then amniotomy is occasionally successful BREECH PRESENTATION Definitions: - suggests that the buttocks occupies the lower segment of the uterus - occurs in 3% of term pregnancies but is common earlier in the pregnancy 1. Breech with knees extended and hips flexed over anterior body (frank) 85% cases 1. Breech with fully flexed legs (complete) 1. Footling (incomplete) with one or both thighs extended Aetiology: - no cause is found in most - a few are accounted by conditions that prevent movement or engagement Risk factors - Prematurity - Multiple prior pregnancies - Polyhydraminos/oligohydraminos - Uterine abnormalities - Fetal abnormalities (Downs syndrome, hydrocephalus) - Macrosomia - Twin gestation - Breech presentation in prior pregnancies - Absolute cephalopelvic disproportion Diagnosis:

- breech presentation is commonly missed (30%) - diagnosis is only important >37 weeks or if patient is in labour - upper abdominal discomfort - hard head is normally palpable and ballotable at the fundus - confirmed by ultrasound (and may help identify cause) Complications: - perinatal and long-term morbidity and mortality - fetal abnormalities - hazards during labour: i) relatively poor fit of the breech leads to an increased rate of cord prolapse ii) head may get trapped (in cephalic presentations, a large head will cause a cessation of progress in labour that is managed easily by Caesarean, but with a breech only after the body has been delivered will the problem be evident) Management: External cephalic version [ECV] - after 37 weeks, an attempt is made to turn the baby to a cephalic presentation - done without anaesthetic, but often with a uterine relaxant (tocolytic) - with both hands on the abdomen, the breech is disengaged from the pelvis and a rotation in the form of a forward somersault is attempted (under ultrasound guidance) - anti-D is given to Rh-negative women - success rate is about 50% - risk is minimal, although placental abruption and uterine rupture have been reported - advantage is reduction in breech presentation at term (ECV <37 weeks does not have this effect) Contraindications to ECV:

- compromised fetus - contraindicated vaginal delivery (e.g. placenta praevia) - twins - ruptured membranes - antepartum haemorrhage - Unfavourable pelvis: android, platypelloid, small - IUGR/macrosomia - Hyperextension of fetal head Mode of delivery - if ECV has failed or is contraindicated, choice is between elective Caesarean section* or an attempt at vaginal delivery - emergency surgery carries higher risks than elective surgery - however, breech presentation is often diagnosed only in late labour, and second twins often present by the breech Patient selection - estimated weight should be <4.0kg to reduce likelihood of entrapped head - no evidence of fetal compromise (e.g. abnormal Doppler, reduced liquor) - legs should not be footling (to reduce the risk of cord prolapse) - head should be well flexed - generous pelvic dimensions (confirmed by X-ray or MRI pelvimetry) - low risk pregnancy [if these criteria are not met, elective Caesarean performed at 39 weeks!] Intrapartum care - in 50%, there is slow cervical dilatation in 1st stage or poor descent in 2nd stage elective Caesarean

- pushing is not encouraged until buttocks are visible - CTG is advised Breech delivery a) once buttocks distend the perineum, an episiotomy is made (i.e. perineum is cut) b) a finger behind the knee flexes the legs out of the vagina, whilst the back is kept anterior c) once scapula is visible, the anterior and then posterior arm is hooked down by a finger over the shoulder sweeping it across the chest d) once the back of the neck is visible, an assistant holds the legs up while the forceps are applied e) head lifted out of vagina with next contraction [alternative = Mauriceau-Smellie-Veit manoeuvre - operator supports entire weight of fetus on one palm and forearm, with finger in its mouth to guide head over perineum and maintain flexion, other hand presses against occiput and an assistant supplies suprapubic pressure] Complications of breech delivery: - Maternal: Placental abruption; 4th degree perineal tear - Fetus: Intracranial haemorrhage; neck trauma due to traction; ruptured viscus (kidney/liver); genital oedema due to caput formation; shoulder and arm trauma on delivery of arms; cord prolapse (footling breech); hip and leg trauma from traction
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