BREECH

 
 
Questions   Answer   Rationale  
1. Factors   associated   with   breech   D. Nulliparity   ETIOLOGY  
presentation   include   all   EXCEPT   which   of   ü Gestational  age  (preterm)  
the  following?   ü Hydramnios  
A. Placenta  previa   ü Uterine  relaxation  associated  with  great  parity  
B. Hydrocephaly   ü Multiple  fetuses  
C. Amniotic  fluid  abnormality   ü Oligohydramnios  
D. Nulliparity   ü Hydrocephaly  
ü Anencephaly  
ü Previous  breech  delivery  
ü Uterine  anomalies  
ü Pelvic  tumor  
ü Placenta  previa  
 
Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
2. Which   of   the   following   finding   is   C. The   ABDOMINAL  EXAMINATION:  LEOPOLD’S  MANEUVER  
st
compatible  with  breech  presentation?   intertrochanteric   • 1   –   hard,   round,   readily   ballotable   fetal   head   is  
A. A   pointed   soft   tissue   mass   on   diameter   has   not   found  to  occupy  the  fundus  
st nd
Leopold’s  1  maneuver   passed   the   • 2   –   indicates   the   back   to   be   on   one   side   of   the  
nd
B. Fetal   back   on   the   left   on   Leopold’s   2   maternal   pelvis   abdomen  and  the  small  parts  on  the  other  
rd
maneuver   on  3  maneuver   rd
• 3   –   if   engagement   has   not   occurred—the  
C. The   intertrochanteric   diameter   has   intertrochanteric  diameter  of  the  fetal  pelvis  has  not  
rd
not   passed   the   maternal   pelvis   on   3   passed   through   the   pelvic   inlet—the   breech   is  
maneuver   movable  above  the  pelvic  inlet  
D. A   round   ballotable   mass   felt   on   th
• 4   –   shows   the   firm   breech   to   be   beneath   the  
th
Leopold’s  4  maneuver   symphysis  
 
Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
3. A  fetus  with  hips  flexed  and  knees  is  BEST   A. Complete  Breech   CLASSIFICATION  OF  BREECH  PRESENTATIONS  
described  as  which  of  the  following?   • Frank   breech   –   the   lower   extremities   are   flexed   at  
A. Complete  Breech   the  hips  and  extended  at  the  knees,  and  thus  the  feet  
B. Frank  Breech   lie  in  close  proximity  to  the  head  
C. Single  footling  breech   • Complete   breech   –   same   as   frank   breech   but   both  
D. Double  footling  breech   knees  are  flexed  
4. Contraindication   to   breech   vaginal   C. Hyperextended   • Incomplete  breech  –  one  or  both  hips  are  not  flexed,  
delivery  includes  which  of  the  following?   head   and   one   or   both   feet   or   knees   lie   below   the   breech,  
A. Frank  breech   such   that   a   foot   or   knee   is   lowermost   in   the   birth  
B. Complete  breech   canal  
C. Hyperextended  head   • Footling   breech   –   incomplete   breech   with   one   or  
D. Aftercoming  breech  presenting  twin   both  feet  below  the  breech  
5. What   is   the  distinguishing   characteristic   of   A. Extension   of   the   • Stargazer   fetus   or   Flying   foetus   (Britain)   –   in   5   %   of  
frank  breech?   knee  joint   term   breech   fetuses,   the   head   may   be   in   extreme  
A. Extension  of  the  knee  joint   hyperextension.   With   such   hyperextension,   vaginal  
B. Flexion  of  the  knee  joint   delivery   may   result   in   injury   to   the   cervical   spinal  
C. Extension  of  the  hip  joint   cord.   Thus,   if   present   after   labor   has   begun,   this   is   an  
D. Flexion  of  the  hip  joint   indication  for  cesarean  delivery.  
6. In  this  type  of  breech  presentation  one  or   C. Incomplete    
th
both  hips  are  flexed,  and  one  or  both  feet   Source:  William’s  Obstetrics,  24  ed.  
or  knees  lie  below  the  breech  such  that  a  
foot   or   knee   is   lowermost   in   the   birth  
canal:  
A. Frank  
B. Complete  
C. Incomplete  
D. All  of  the  above  
 
7. When   planning   for   a   vaginal   breech   A.   Unlike   IMAGING  TECHNIQUES  
delivery,   pelvic   dimension,   type   of   breech   cephalic   • In  many  fetuses—especially  those  that  are  preterm—
and   degree   of   neck   flexion   or   extension   presentation,   the   the  breech  is  smaller  than  the  aftercoming  head.    
must   be   identified   using   imaging   head   of   breech   • Moreover,  unlike  cephalic  presentations,  the  head  of  
techniques.   Trapping   of   the   fetal   head   presenting   fetus   is   a   breech-­‐presenting   fetus   does   not   undergo  
may  occur  because-­‐   not   permitted   to   appreciable  molding  during  labor.    
A. Unlike   cephalic   presentation,   the   undergo   molding   • Thus,   to   avoid   head   entrapment   following   delivery   of  
head   of   breech   presenting   fetus   is   not   during  labor   the   breech,   pelvic   dimensions   should   be   assessed  
permitted   to   undergo   molding   during   before  vaginal  delivery.    
labor   • In   addition,   fetal   size,   type   of   breech,   and   degree   of  
B. Most   of   the   fetuses   are   preterm   and   neck  flexion  or  extension  should  be  identified.    
the   breech   is   larger   than   the   • To   evaluate   these,   several   imaging   techniques   can   be  
aftercoming  head   used.  
C. Most  of  the  mothers  have  contracted    
pelvis   predisposing   the   fetus   to   th
Source:  William’s  Obstetrics,  24  ed.  
assume  a  breech  presentation    
D. All  of  the  above   IMAGING  TECHNIQUES  
  • ULTRASOUND  
8. The   BEST   way   to   confirm   a   suspected   C. Ultrasound   o used   to   confirm   a   clinically   suspected   breech  
breech   presentation   is   which   of   the   presentation   and   to   identify,   if   possible,   any  
following?   fetal  anomalies  
A. Leopold’s  Maneuver   o If   cesarean   delivery   is   planned,   additional  
B. MRI   imaging   is   not   indicated.   If,   however,   vaginal  
C. Ultrasound   delivery   is   considered,   the   type   of   breech  
D. CT  scan   presentation   and   the   degree   of   flexion   or  
  deflexion  of  the  head  is  important.  
9. A   planned   vaginal   delivery   is   considered   in   B. Ultrasound   • CT  SCAN  
a   term   pregnancy.   What   is   the   BEST   o will   provide   pelvic   measurements   and  
diagnostic  modality  to  determine  whether   configuration   at   lower   doses   of   radiation   than  
it  is  possible  for  the  choice?   standard  radiography  
A. Leopold’s  maneuver   • MRI  
B. Ultrasound   o provides   reliable   information   about   pelvic  
C. MRI   capacity   and   architecture   without   ionizing  
D. CT  Scan   radiation  
o not  always  readily  available  
 
Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
 
10. Why   is   breech   presentation   better   D. Delayed  head   TERM  BREECH  FETUS  
delivered  by  CS?   accommodation   • PLANNED  VAGINAL  DELIVERY  
A. Aftercoming   head   is   a   slow   cervical   to  the  pelvis  may   o Increased  neonatal  mortality  and  morbidity  
dilator   lead  to  hypoxia   o Causes  of  death  were  head  entrapment,  
B. Delayed   head   accommodation   to   the   o Cerebral   injury   and   intracranial   hemorrhage,  
pelvis  may  lead  to  hypoxia   cord  prolapse,  and  severe  asphyxia  
C. Breech  will  require  a  lot  of  maneuver   • PLANNED  CS  DELIVERY:  PRETERM  FETUS  
D. Meconium   is   passed   out   earlier   in   o The   aftercoming   head   of   a   preterm   fetus   may   be  
breech   trapped   by   a   cervix   that   is   sufficiently   effaced  
and   dilated   to   allow   passage   of   the   thorax   but  
not  of  the  less-­‐compressible  head.  
o The   consequences   of   vaginal   delivery:   hypoxia  
and  physical  trauma  
o Preterm   infants   undergoing   cesarean   delivery  
had  a  better  prognosis  
 
Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
 
 
 
11. A   35   years   old   G3P3,   38   weeks   in   labor,   C. Cesarean  section   FACTORS   FAVORING   CESAREAN   DELIVERY   OF   THE  
breech  presentation.  Patient  desires  tubal   and  tubal  ligation   BREECH  FETUS  
ligation.   Estimated   fetal   weigh   is   2500   ü Lack  of  operator  experience  
grams.  What  is  the  manner  of  delivery  for   ü Patient  request  for  cesarean  delivery  
the  patient?   ü Large  fetus:  >  3800  to  4000  g  
A. Spontaneous  vaginal  breech  delivery   ü Apparently   healthy   and   viable   preterm   fetus   either  
B. Cesarean  section   with  active  labor  or  with  indicated  delivery  
C. Cesarean  section  and  tubal  ligation   ü Severe  fetal-­‐growth  restriction  
D. Partial  breech  extraction   ü Fetal  anomaly  incompatible  with  vaginal  delivery  
12. Which   of   the   following   breech   B. Complete   breech   ü Prior  perinatal  death  or  neonatal  birth  trauma  
presentation   in   labor   will   be   delivered   36   weeks,   with   ü Incomplete  or  footling  breech  presentation  
vaginally?   anencephaly   ü Hyperextended  head  
A. Frank   breech,   37   weeks,   estimated     ü Pelvic   contraction   or   unfavorable   pelvic   shape  
fetal  weight  –  2900  grams   -­‐The   rest   of   the   determined  clinically  or  with  pelvimetry  
B. Complete   breech,   36   weeks,   with   choices   are   ü Prior  cesarean  delivery  
anencephaly   indications   for    
th
C. Footling   breech,   35   weeks   with   cesarean  section   Source:  William’s  Obstetrics,  24  ed.  
gastroischisis    
D. Double   footling   breech,   37   weeks,   RECOMMENDATIONS  FOR  DELIVERY  
weight  2200  grams   Cesarean  delivery  is  commonly  but  not  exclusively  used  in  
13. Cesarean  delivery  for  breech  presentation   C. Anencephalic   the  following  circumstances:  
is   commonly   used   in   the   following   fetus   in   breech   ü A  large  fetus  
circumstances,  EXCEPT   presentation   ü Any   degree   of   contraction   or   unfavorable   shape   of  
A. Any   degree   of   contraction   or   the  pelvis  
unfavorable  shape  of  the  pelvis   ü A  hyperextended  head  
B. A  hyperextended  head   ü When   delivery   is   indicated   in   the   absence   of  
C. Anencephalic   fetus   in   breech   spontaneous   labor   (some   clinicians   use   oxytocin  
presentation   augmentation)  
D. Incomplete  or  footling  breech   ü Uterine   dysfunction   (some   use   oxytocin  
E. A  request  for  sterilization   augmentation)  
14. Angie,   G2P1,   38-­‐39   weeks   AOG,   came   to   D. Emergency  CS   ü Incomplete  or  footling  breech  presentation  
your   office   complaining   of   hypogastric     ü An  apparently  healthy  and  viable  preterm  fetus  with  
pains.   IE   revealed   cx   5-­‐6cms   dilated,   60-­‐ -­‐Incomplete   or   the   mother   in   either   active   labor   or   in   whom   delivery  
70%   effaced,   plantar   surface   of   the   left   footling  breech   is  indicated  
foot   is   most   leading   at   the   birth   canal   with   ü Severe  fetal  growth  restriction  
intact   BOW.   How   will   you   manage   the   ü Previous   perinatal   death   or   children   suffering   from  
case?   birth  trauma  
A. Monitor  progress  of  labor  and  deliver   ü A  request  for  sterilization  
by  breech  extraction   ü Lack  of  an  experienced  operator  
B. Rupture  BOW,  put  on  Trendelenbrg  to    
prevent   prolapse   of   cord   and   do   a   Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
total  breech  extraction  
C. Rupture   the   bag   of   water   and   deliver  
by  cesarean  section  
D. Emergency  CS  
15. Which   of   the   following   statements   about   A. Descent  takes   Engagement  and  Descent  
the   mechanism   of   labor   in   breech   place  with   • usually   take   place   with   the   bitrochanteric   diameter   in  
presentation  is  correct?   bitrochanteric   one  of  the  oblique  pelvic  diameters  
A. Descent   takes   place   with   diameter  in  the   • The   anterior   hip   usually   descends   more   rapidly   than  
bitrochanteric  diameter  in  the  oblique   oblique  diameter   the  posterior  hip  
diameter  of  the  pelvis   of  the  pelvis   • when  the  resistance  of  the  pelvic  floor  is  met,  internal  
B. Posterior   hip   descends   rapidly   than   rotation   of   45   degrees   usually   follows,   bringing   the  
the  anterior  hip   anterior   hip   toward   the   pubic   arch   and   allowing   the  
C. Internal   rotation   of   90   degrees   bitrochanteric   diameter   to   occupy   the  
allowing   the   bitrochanteric   diameter   anteroposterior  diameter  of  the  pelvic  outlet.  
to   occupy   the   transverse   diameter   of   • If   the   posterior   extremity   is   prolapsed,   however,   it  
the  pelvis     rotates   to   the   symphysis   pubis   rather   than   the  
D. All  of  the  above   anterior  hip.  
 After  Rotation  
• descent   continues   until   the   perineum   is   distended   by  
the   advancing   breech,   and   the   anterior   hip   appears  
at  the  vulva.  
• By  lateral  flexion  of  the  fetal  body,  the  posterior  hip  
then  is  forced  over  the  perineum,  which  retracts  over  
the   buttocks,   thus   allowing   the   infant   to   straighten  
out  when  the  anterior  hip  is  born.  
• The   legs   and   feet   follow   the   breech   and   may   be   born  
spontaneously  or  with  aid.  
After  Birth  of  the  Breech  
• there   is   SLIGHT   EXTERNAL   ROTATION,   with   the   back  
turning   anteriorly   as   the   shoulders   are   brought   into  
relation   with   one   of   the   oblique   diameters   of   the  
pelvis.  
• The   shoulders   then   DESCEND   rapidly   and   undergo  
INTERNAL   ROTATION,   with   the   bisacromial   diameter  
occupying  the  anteroposterior  plane.  
• Immediately   following   the   shoulders,   the   head,  
which   is   normally   sharply   flexed   upon   the   thorax,  
enters   the   pelvis   in   one   of   the   oblique   diameters   and  
then   rotates   in   such   a   manner   as   to   bring   the  
posterior   portion   of   the   neck   under   the   symphysis  
pubis.  
• The  head  is  then  born  in  flexion.  
 
Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
16. Which   of   the   following   characterizes   B. Infant   3  GENERAL  METHODS  OF  BREECH  DELIVERY  
partial  breech  extraction?   spontaneously   • SPONTANEOUS   BREECH   DELIVERY   –   The   infant   is  
A. Infant  expelled  entirely  to  shoulder   delivers   to   expelled  entirely  spontaneously  without  any  traction  
B. Infant   spontaneously   delivers   to   umbilicus   or  manipulation  other  than  support  of  the  infant  
umbilicus   • PARTIAL   BREECH   EXTRACTION   –   The   infant   is  
C. Infants   buttocks   deliver   delivered   spontaneously   as   far   as   the   umbilicus,   but  
spontaneously   the   remainder   of   the   body   is   extracted   or   delivered  
D. Infant  extracted  by  the  attendant   with  operator  traction  and  assisted  maneuvers,  with  
17. Marilou,   a   25   year   old   multipara   on   her   C.
Do  partial  breech   or  without  maternal  expulsive  efforts.  
nd
32   week   of   gestation,   is   brought   to   the   extraction   • TOTAL  BREECH  EXTRACTION  –  The  entire  body  of  the  
emergency  room,  with  her  baby  in  breech   infant  is  extracted  by  the  obstetrician  
presentation   with   the   lower   extremities    
and   the   body   up   to   the   navel   already   out   Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
of   the   introitus.   What   will   be   the   best  
approach  for  this  case?  
A. Emergency  cesarean  section  
B. Observe   further   for   spontaneous  
breech  delivery  
C. Do  partial  breech  extraction  
D. Do  total  breech  extraction  
18. How  should  traction  in  a  breech  extraction   D. Gentle   PARTIAL  BREECH  EXTRACTION  
be  employed?   downward   A   cardinal   rule   in   successful   breech   extraction   is   to  
A. Parallel  to  the  floor   traction   employ   steady,   gentle,   downward   traction   until   the   lower  
B. 30  degree  angle  toward  the  ceiling   halves   of   the   scapulas   are   delivered,   making   no   attempt  
C. Gentle  downward  traction   at   delivery   of   the   shoulders   and   arms   until   one   axilla  
D. Marked  downward  pull  until  axilla  are   becomes  visible.  
visible    
th
Source:  William’s  Obstetrics,  24  ed.  
 
 
 
19. In   which   maneuver   are   the   index   and   the   C. Mauriceau   DELIVERY  OF  THE  AFTERCOMING  HEAD  
middle   finger   applied   over   the   maxilla   in   • Mauriceau   maneuver   –   the   index   and   middle   finger  
order  to  free  the  head?   of  one  hand  are  applied  over  the  maxilla,  to  flex  the  
A. Pinard   head,   while   the   fetal   body   rests   on   the   palm   of   the  
B. Bracht   hand  and  forearm  
C. Mauriceau   • Prague   maneuver   –   may   be   used   if   the   back   of   the  
D. Zavanelli   fetus  fails  to  rotate  to  the  anterior.  When  this  occurs,  
20. What   maneuver   in   breech   delivery   C. Mauriceau   rotation  of  the  back  to  the  anterior  may  be  achieved  
involves   pressing   the   malar   area   of   the   by   using   stronger   traction   on   the   fetal   legs   or   bony  
fetus  with  the  fingers  to  prevent  extension   pelvis.   If   the   back   still   remains   oriented   posteriorly,  
of  the  aftercoming  head?   extraction  may  be  accomplished  using  the  Mauriceau  
A. Bracht   maneuver  and  delivering  the  fetus  back  down.  
B. Lovset   • Modified  Prague  maneuver  -­‐  consists  of  two  fingers  
C. Mauriceau   of   one   hand   grasping   the   shoulders   of   the   back-­‐down  
D. Prague   fetus   from   below   while   the   other   hand   draws   the   feet  
21. In   this   maneuver,   the   index   and   middle   C. Mauriceau   up  and  over  the  maternal  abdomen  
fingers   of   one   hand   are   applied   over   the   • Zavanelli  maneuver  -­‐  replacement  of  the  fetus  higher  
maxilla,   to   flex   the   head,   while   the   fetal   into   the   vagina   and   uterus,   followed   by   cesarean  
body   rests   on   the   palm   of   the   hand   and   delivery,   to   rescue   an   entrapped   breech   fetus   that  
forearm:   cannot  be  delivered  vaginally  
A. Prague    
B. Pinard   DELIVERY  OF  ARMS  
C. Mauriceau   • Lovset  maneuver  –  rotation  of  the  trunk  of  the  fetus  
D. Zavanelli   during  a  breech  birth  to  facilitate  delivery  of  the  arms  
  and  the  shoulders.  Done  if  arms  are  stretched  above  
22. Which   of   the   following   maybe   necessary   D. Prague   the  head  or  folded  around  the  neck.  (online)  
to  deliver  the  aftercoming  head  if  the  fetal   maneuver    
trunk  fails  to  rotate  anteriorly?   TOTAL  BREECH  EXTRACTION  
A. Laufe  forceps   • Pinard   maneuver   –   Two   fingers   are   inserted   along  
B. Pipers  forceps   one   extremity   to   the   knee,   which   is   then   pushed  
C. Mauriceau  maneuver   away   from   the   midline   after   spontaneous   flexion.  
D. Prague  maneuver   Traction  is  used  to  deliver  a  foot  into  the  vagina.  
23. On  partial  breech  extraction,  there  was  an   D. Prague   • Bracht   maneuver   –   Delivery   of   a   fetus   in   breech  
unsuccessful   rotation   of   the   fetal   body   to   position  by  extending  the  legs  and  trunk  of  the  fetus  
put   the   back   up.   Which   of   the   following   over   the   pubic   symphysis   and   abdomen   of   the  
maneuver  can  be  used  to  effect  delivery?   mother,   which   leads   to   spontaneous   delivery   of   the  
A. Lovset   fetal   head.   (online:   The   American   Heritage®  
B. Mauriceau   Stedman's  Medical  Dictionary)  
C. Pipers    
th
D. Prague   Source:  William’s  Obstetrics,  24  ed.  
24. Ana,   a   second   year   OB   resident,   is   D. Two   fingers   of  
delivering   a   baby   in   breech   presentation   one   hand  
vaginally,  she  notices  that  the  back  of  the   grasping   the  
fetus   fails   to   rotate   tot   the   anterior.   She   shoulders   from  
now   proceeds   to   do   the   modified   Prague   down   below  
maneuver  which  consists  of:   while   the   other  
A. Using   stronger   traction   on   the   fetal   hand   draws   the  
legs  or  bony  pelvis   feet   up   over   the  
B. Applying   the   index   and   middle   finger   maternal  
of   one   hand   over   the   maxilla,   and   abdomen  
delivering  the  fetus  back  down    
C. Using  the  Piper  forceps  and  delivering   A-­‐Prague  
the  fetus  back  down   B-­‐Mauriceau  
D. Two  fingers  of  one  hand  grasping  the  
shoulders  from  down  below  while  the  
other  hand  draws  the  feet  up  over  the  
maternal  abdomen    
 
25. Which   of   the   following   forceps   is   BEST   D. Pipers   TYPES  OF  FORCEPS  
suited   for   the   delivery   of   the   aftercoming   • SIMPSON  FORCEPS  
head?   o Most   common   forceps   with   cephalic   and   pelvic  
A. Simpson   curve  
B. Kielland   o Parallel  shanks  
C. Tucker  Mclain   o Fenestrated  blade  and  the  wide  shank  in  front  of  
D. Pipers   the  English-­‐style  lock  
  o English   lock,   consists   of   a   socket   located   on   the  
26. There   was   difficulty   in   extracting   the   B. Use   Pipers   shank  at  the  junction  with  the  handle,  into  which  
aftercoming   head   using   the   Mauriceau   forceps   fits   a   socket   similarly   located   on   the   opposite  
maneuver.   Which   of   the   following   can   be   shank  
the  next  step?   o use   to   deliver   the   fetus   with   molded   head  
A. Wait  for  spontaneous  delivery   (nulliparous)  
B. Use  Pipers  forceps   • TUCKER-­‐MCLANE  FORCEPS  
C. Pull  harder   o blade  is  solid  and  the  shank  is  narrow  
D. Do  Duhrsen’s  incision   o method  of  articulation  -­‐  English  lock  
o use   to   deliver   the   fetus   with   rounded   head  
(multiparous)  
• KIELLAND  FORCEPS  
o characteristic   features   are   the   sliding   lock,  
minimal   pelvic   curvature,   and   light   weight   for  
deep  transverse  arrest  
• PIPER  FORCEPS  
o blade  is  similar  to  Simpson  
o shank  is  longer  
o it   has   a   double   pelvic   curve   to   facilitate  
application   to   the   aftercoming   head   in   breech  
presentation  
• BARTON  FORCEPS  
o good   forceps   for   rotation   of   head   in   transverse  
arrest  
 
Source:   OB3B   –   Forceps   Delivery   and   Vacuum   Extraction  
DrVillamar  (Bernabe)  
 
DUHRSSEN’S  INCISION  
• At   10   o'clock   (already   cut)   and   2   o'clock   (being   cut  
with   bandage   scissors)   to   relieve   entrapped  
aftercoming  head.  Infrequently,  an  additional  incision  
is  required  at  6  o'clock  
• The   incisions   are   so   placed   as   to   minimize   bleeding  
from   the   laterally   located   cervical   branches   of   the  
uterine  artery.  
• Done  if  there  is  a  entrapment  of  the  fetal  arm  behind  
the   neck   (nuchal   arm),   which   complicates   up   to   6   %  
of   vaginal   breech   deliveries   and   is   associated   with  
increased  neonatal  mortality  
 
Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
 
 
 
 
 
 
 
 
 
27. Zeny,  a  30  year  old  primipara  was  brought   B. Difficult  delivery   MATERNAL  MORBIDITY  AND  MORTALITY  
in   to   the   emergency   room   because   of   of  the   • For   the   mother,   with   either   cesarean   or   vaginal  
profuse   vaginal   bleeding.   2   hours   prior   to   aftercoming   delivery,  genital  tract  laceration  can  be  problematic.  
consult   she   had   a   vaginal   breech   delivery   head   • With   cesarean   delivery,   added   stretching   of   the  
in   a   lying-­‐in   clinic.   Examination   disclosed   lower   uterine   segment   by   forceps   or   by   a   poorly  
nd
the   uterus   to   be   well   contracted,   2   molded  fetal  head  can  extend  hysterotomy  incisions.    
degree  perineal  tears  with  slight  bleeding,   • With   vaginal   delivery,   especially   with   a   thinned   lower  
and   profuse   bleeding   coming   from   the   uterine   segment,   delivery   of   the   aftercoming   head  
vagina  and  cervix.  This  is  most  likely  due  to   through  an  incompletely  dilated  cervix  or  application  
what   complication   of   vaginal   breech   of   forceps   may   cause   vaginal   wall   or   cervical  
delivery?   lacerations.  
A. Rupture  of  the  uterus   • Manipulations  may  also  extend  an  episiotomy,  create  
B. Difficult   delivery   of   the   aftercoming   deep  perineal  tears,  and  increase  infection  risks.    
head   • Anesthesia   sufficient   to   induce   appreciable   uterine  
C. Genital  tract  lacerations   relaxation   during   vaginal   delivery   may   cause   uterine  
D. Uterine  atony   atony  and  in  turn,  postpartum  hemorrhage.  
• Death  is  a  rare  complication,  but  rates  appear  higher  
in   those   with   planned   cesarean   delivery   for   breech  
presentation.  
 
th
Source:  William’s  Obstetrics,  24  ed.    
28. Which  of  the  following  are  potential  risk/s   D. All  of  the  above   PERINATAL  MORBIDITY  AND  MORTALITY  
to  the  fetus  in  breech  extraction?   • Some   of   the   more   common   injuries   are   fractures   of  
A. Intracranial  hemorrhage   the  humerus,  clavicle,  and  femur.  
B. Tentorial  tears   • In   some   cases,   traction   may   separate   scapular,  
C. Paralysis   humeral,  or  femoral  epiphyses.  
D. All  of  the  above   • Rare  traumatic  injuries  may  involve  bony/soft  tissues.  
• Neonatal   perineal   tears   have   been   reported   from  
fetal  scalp  electrodes.    
• Upper   extremity   paralysis—Erb   or   Duchenne—may  
follow  brachial  plexus  stretching.    
• When   the   fetus   is   extracted   through   a   contracted  
pelvis,   spoon-­‐shaped   depressions   or   actual   fractures  
of  the  skull  may  result.  (?)  
• The  spinal  cord  may  be  injured  or  vertebra  fractured  
if  great  force  is  employed.    
• Hematomas  of  the  SCM  muscles  occasionally  develop  
after  delivery,  but  usually  disappear  spontaneously.    
• Last,  testicular  injury  may  follow  breech  delivery.  
 
th
Source:  William’s  Obstetrics,  24  ed.    
29. Which   of   the   following   condition   is   A. Multiparity   EXTERNAL  CEPHALIC  VERSION  
favorable  for  external  cephalic  version?   Several   factors   can   improve   the   chances   of   a   successful  
A. Multiparity   version  attempt.  These  include:    
B. Amniotic  fluid  index  of  8   ü Multiparity  
C. Station  -­‐1   ü Abundant  amnionic  fluid  
D. Estimated   fetal   weight   of   3400   –   3500   ü Unengaged  presenting  part  
grams   ü Fetal  size  2500  to  3000  g  
ü Posterior  placenta  
ü Nonobese  patient  
 
th
Source:  William’s  Obstetrics,  24  ed.  
30. Which   of   the   following   modalities   will   B. Nonstress  test   EXTERNAL  CEPHALIC  VERSION  
assure   fetal   well-­‐being   after   an   external   TECHNIQUE  
cephalic  version?   • UTZ  is  performed  to  confirm  nonvertex  presentation  
A. Epidural  analgesia   and   adequacy   of   amnionic   fluid   volume,   to   rule   out  
B. Nonstress  test   obvious  fetal  anomalies  if  not  done  previously,  and  to  
C. Tocolysis   identify  placental  location  
D. Ultrasound   • External   monitoring   is   performed   to   assess   fetal  
  heart  rate  reactivity.  
31. Mara,   a   19   year   old   primigravida,   on   her   C.
Counterclockwise   • The   nonstress   test   is   repeated   after   version   until   a  
th
36   week   of   gestation   came   for   prenatal   pressure   is   normal  test  result  is  obtained  
check-­‐up.   Examination   disclosed   the   fetus   exerted   against   • FORWARD  ROLL  
to   be   in   breech   presentation,   FHT   the  fetal  head   o Each  hand  grasps  one  of  the  fetal  poles,  and  the  
140/min,   cervix   close,   BOW   intact,   frank   buttocks   are   elevated   from   the   maternal   pelvis  
breech,   floating.   The   following   describe   and  displaced  laterally.  
the   forward   roll   of   the   fetus   for   external   o The   buttocks   are   then   gently   guided   toward   the  
cephalic  version,  EXCEPT   fundus,   while   the   head   is   directed   toward   the  
A. Each   hand   grasps   one   of   the   fetal   pelvis  
poles   o Clockwise   pressure   is   exerted   against   the   fetal  
B. The   buttocks   are   elevated   from   the   poles  (Williams)  
maternal  pelvis  and  displaced  laterally   • BACKWARD  FLIP  
C. Counterclockwise   pressure   is   exerted   • CONDUCTION   ANALGESIA   –   increased   success   with  
against  the  fetal  head   version  when  epidural  analgesia  is  used  
D. The   buttocks   are   gently   guided   • TOCOLYSIS  –  uterine  relaxation  with  a  tocolytic  agent  
toward   the   fundus,   and   the   head   is    
directed  toward  the  pelvis   Source:  OB3B  –  Breech  –  DraMusa(Bernabe)  
th
32. Trixie,   a   teenaged   primigravida   on   her   36   A. Terbutaline   TOCOLYSIS  
week   of   gestation   comes   to   the   clinic   • Existing   evidence   may   support   the   use   of   tocolytic  
complaining   of   labor   pains.   Examination   agents  during  external  version  attempts  
discloses   the   baby   to   be   in   breech   • Agents  investigated  include:  
presentation,   floating,   cervix   1   to   2   cm   o Betamimetics   (ex.   terbutaline,   ritodrine,   or  
dilated,   in   beginning   effacement,   BOW   salbutamol)  
intact,   frank   breech.   Which   of   the   o Calcium  channel  blockers  (ex.  nifedipine)  
following   tocolytic   agents   has   been   o Nitric  oxide  donors  (ex.  nitroglycerin)  
reported   to   have   high   success   rate   to   • Most   randomized   investigations   have   evaluated  
control   the   uterine   contractions   so   betamimetics.   One   trial   reported   that   the   success  
external   cephalic   version   can   be   done   rate   with   subcutaneous   terbutaline   (52%)   was  
subsequently?   significantly  higher  than  without  (27%).    
A. Terbutaline   • There   is   less   evidence   to   support   the   use   of  
B. Ritodrine   nifedipine  and  nitroglycerin.  
C. Salbutamol    
D. Glyceryl  trinitrate   th
Source:  William’s  Obstetrics,  24  ed.