Management Of Malpresentation And Malposition Especially Breech Presentation

1. 
   TITLE: 

Management Of Malpresentation And Malposition Especially Breech Presentation .

2. PURPOSE:

To standardize the health care provided to patients with malpresentation and malposition especially breech presentation at term.

3. CONDITION/ APPLICABILITY:

Applies to all Medical/Nursing staff of Obstetrics and Gynecology.

4. DEFINITION :

N/A

5. POLICY: 

1. Cases of breech presentation should be seen in OPD by the consultant to decide upon plan of management.

2. All singleton breech presentation and all twins with the first twin breech presentation are for elective Caesarean Section unless patient request for vaginal breech delivery.

3. In case the couple request for vaginal breech delivery they should be counseled regarding the pros & cons of planned Vaginal Delivery VS planned Caesarean Section.

4. Upon admission to LAD the consultant should be informed to set the plan of management. 

5. "Assisted breech delivery" should be conducted by clinically privileged specialist or the consultant on-duty.

6. There is no place for breech extraction for singleton breech (only allowed for second twin).

7. Elective C.S. should be done at 39-40 weeks to give time for spontaneous cephalic version.

8. External cephalic version (ECV) is encouraged and its practice depends upon the experience of the treating consultant.

9. Women should be assessed carefully before selection for vaginal breech birth and a written consent should be taken.

10. Factors regarded as unfavorable for vaginal beech birth include the following :

1. Other contraindications to vaginal birth (e.g. placenta Previa, compromised fetal condition). 

2. Clinically inadequate pelvis.

3. Footling breech presentation.

4. Large baby (usually defined as larger than 4000 grams).

5. Growth-restricted baby (usually defined as less than 10th centile ).

6. Hyperextended fetal neck in labor (diagnosed with ultrasound or x ray ).

7. Lack of presence of clinician trained in vaginal breech delivery.

8. Previous caesarean section.

11. An undiagnosed breech presenting in labor should be discussed with the consultant on call.

12. Un booked breech presentation presented in labor should be counseled regarding mode of delivery and written consent for vaginal delivery should be taken.

13. Detailed intrapartum ultrasound to be performed (expected fetal weight and major congenital anomalies to be excluded if not performed earlier). 

14. Gravid women can be allowed to have vaginal delivery if presented in advanced stage of labor and delivery is imminent or to multifetal gestation if second non vertex after counseling and consent .

15. Presentation of the mother in advanced labor with no maternal or fetal distress even if caesarean section originally planned can be allowed to have vaginal delivery after counseling and consent.

16. Other malpresentation and malposition will be managed as follows provided no other complications arises  :

1. Face mento-anterior vaginal delivery .

2. Face mento-posterior caesarean section .

3. Brow caesarean section .

4. Transverse lie caesarean section .

5. Oblique / unstable Lie stabilizing induction and caesarean section in case of emergency .

6. PROCEDURES: 

1. contact the consultant and inform the anesthesia.

1. The registrar should be available to confirm the diagnoses, confirmation of full dilatation should be undertaken by the obstetric registrar.

2. Continues electronic fetal heart monitoring should be employed.

3. Caesarean section should be considered if there is delay in the descent of the breech at any stage in the second stage of labor.

4. Oxytocin use to be decided by consultant.

5. Offer the patient epidural anesthesia 

2. Vaginal breech delivery 

1. Delivery should be conducted in lithotomy position. 

2. Vaginal examination should be performed following rupture of membrane to exclude a footling breech and cord prolapse.

3. Episiotomy should be performed when indicated to facilitate delivery.

4. The pediatrician must be present at delivery, and the anesthetist available in the operation theatre.

5. No traction should be applied while the baby is being delivered and the body is allowed to hang. The operator should guide the body to keep the sacrum anterior. 

6. Allow spontaneous delivery of the trunk and limbs.

7. Perform lovset maneuver (rotation of the baby to facilitate delivery of the arms). 

8. Supra-pubic pressure by an assistant can be used to assist flexion of the head.

9. The after coming head maybe delivered with forceps, the Mauriceau–Smellie–Veit maneuver or the burns-marshall method.

10. Removal of placenta, episiotomy repair as routine. 

3. UN-diagnosed breech :

1. ECV may be  considered and offered if this is acceptable to the woman provide that she is 37 weeks gestation , the membranes are intact , there are no contraindications to ECV and the clinician is suitably experienced in performing CV . 

2. Women presenting in advanced labor with undiagnosed breech presentation should be counselled regarding the risks and benefits of vaginal breech delivery and emergency Caesarean Section.

3. Breech extraction should never be undertaken except in the case of a second twin or a dead fetus. 

4. Cesarean Section is the mode of delivery for footling breech. 

4. Management of the preterm breech and twin breech 

1. Routine cesarean section for the delivery of preterm breech presentation should be advised with counselling the patient and her partner. 

2. If the second twin is breech after delivery of the first twin, vaginal breech delivery is the method of choice. 

5. Malpresentation and malposition 

1. Admission , assessment and monitoring of the patient should follow the same procedure as other patient in labor . 

2. After the complete assessment and confirmation of malpresentation or malposition the mode of delivery is chosen as specified in the policy .

3. In case of oblique/unstable lie stabilizing induction in carried out as follows 

   1. controlled rupture of membranes is done with full preparation of caesarean section

   2. If cord prolapse occurs patient is taken for urgent caesarean section  

   3. Otherwise immediate Oxytocin is started with careful maternal positioning and continuous  fetal monitoring is carried out .

6. Documentation : details of care should be clearly documented, including details of counseling and the identity of all those involved in the procedures.

7. Secondary documents : 

1. History and examination form.

2. Ultrasound form.

3. CTG.

4. Partogram.

7. RESPONSIBILITY:

1. OB/GYNE Consultant

2. Specialist

3. Registered Midwife 

8. FORMS/ EQUIPMENT:

N/A

9. REFERENCE:

1. Oxford text reference in obstetrics and gynecology (2011)

2. Obstetrics and Gynecology, An evidence based text for MRCOG 3rd addition  (2016)

                                                                                         
REVISION:

11. APPROVALS: