cephalic presentation with polyhydramnios

Patient Care & Health Information
Diseases & Conditions
Polyhydramnios

Polyhydramnios during pregnancy

In polyhydramnios, increased levels of amniotic fluid accumulates in the uterus during pregnancy. Mild cases of polyhydramnios may go away on their own. Severe cases may require treatment.

Polyhydramnios (pol-e-hi-DRAM-nee-os) is the buildup of increased amniotic fluid — the fluid that surrounds the baby in the uterus during pregnancy. Polyhydramnios happens in about 1% to 2% of pregnancies.

Most of the time, the condition is mild. It's often found during the middle or later stages of pregnancy. Severe polyhydramnios may cause shortness of breath, preterm labor or other symptoms.

If you learn that you have polyhydramnios, your health care team carefully tracks your pregnancy to help prevent health problems. Treatment depends on how serious the condition is. Mild polyhydramnios may go away on its own. Severe polyhydramnios may need to be watched more closely by your care team.

Products & Services

A Book: Mayo Clinic Family Health Book, 5th Edition
A Book: Mayo Clinic Guide to a Healthy Pregnancy
Newsletter: Mayo Clinic Health Letter — Digital Edition

Polyhydramnios symptoms may be linked with the buildup of amniotic fluid creating pressure within the uterus and on nearby organs. Mild polyhydramnios often causes few or no symptoms. But serious forms of the condition may cause:

Shortness of breath or not being able to breathe.
Swelling in the ankles or feet.
Pain in the stomach area.
Feelings of tightness in the muscles of the uterus, called contractions.

Your health care professional also may also suspect polyhydramnios if your uterus has become large for the number of weeks of pregnancy.

Some of the known causes of polyhydramnios include:

Conditions that affect the baby's digestive tract, central nervous system or certain other organs.
Genetic conditions that affect the baby.
Diabetes in the pregnant person.
A complication of identical twin pregnancies in which one twin receives too much blood and the other too little. This is called twin-to-twin transfusion syndrome.
A decreased amount of red blood cells in the baby, also called fetal anemia.
A condition in which the pregnant parent's blood cells attack the baby's blood cells.
Infection during pregnancy.

Often, the cause of polyhydramnios isn't clear, especially when the condition is mild.

Risk factors

Risk factors for polyhydramnios include certain conditions that develop during pregnancy, such as gestational diabetes. A condition that affects the developing baby, such as a problem with the digestive tract, central nervous system or other organs, may also put you at risk of polyhydramnios.

Complications

Polyhydramnios is linked with:

The baby being born too early, also called premature birth.
The baby not being head-down in the ideal position before delivery, also called a breech birth.
The water breaking early, also called premature rupture of membranes.
The baby's umbilical cord dropping into the vagina ahead of the baby, also called umbilical cord prolapse.
The organ that provides oxygen and nutrients to the unborn baby, the placenta, peeling away from the inner wall of the uterus before delivery. This is called placental abruption.
Need for a C-section delivery.
Pregnancy loss after 20 weeks, also called stillbirth.
Heavy bleeding due to decreased uterine muscle tone after delivery.

Greater health problems usually are linked with severe polyhydramnios.

Beloosesky R, et al. Polyhydramnios: Etiology, diagnosis, and management. https://www.uptodate.com/contents/search. Accessed June 30, 2023.
Polyhydramnios. Merck Manual Professional Version. https://www.merckmanuals.com/professional/gynecology-and-obstetrics/abnormalities-of-pregnancy/polyhydramnios. Accessed June 30, 2023.
Landon MB, et al., eds. Amniotic fluid disorders. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed June 30, 2023.
Polyhydramnios (too much amniotic fluid). National Health Service. https://www.nhs.uk/conditions/polyhydramnios/. Accessed June 30, 2023.
Wick MJ (expert opinion). Mayo Clinic. July 8, 2023.

Associated Procedures

Amniocentesis
Glucose challenge test
Symptoms & causes
Diagnosis & treatment

Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission.

Opportunities

Mayo Clinic Press

Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press .

Mayo Clinic on Incontinence - Mayo Clinic Press Mayo Clinic on Incontinence
The Essential Diabetes Book - Mayo Clinic Press The Essential Diabetes Book
Mayo Clinic on Hearing and Balance - Mayo Clinic Press Mayo Clinic on Hearing and Balance
FREE Mayo Clinic Diet Assessment - Mayo Clinic Press FREE Mayo Clinic Diet Assessment
Mayo Clinic Health Letter - FREE book - Mayo Clinic Press Mayo Clinic Health Letter - FREE book

Your gift holds great power – donate today!

Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine.

cephalic presentation with polyhydramnios

Fetal Presentation, Position, and Lie (Including Breech Presentation)

Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

1 Definitions
2 Risk Factors
3.2 Presentation
3.3 Position
4 Investigations
5.1 Abnormal Fetal Lie
5.2 Malpresentation
5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

Longitudinal, transverse or oblique
Cephalic vertex presentation is the most common and is considered the safest
Other presentations include breech, shoulder, face and brow
Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

Multiple pregnancy
Uterine abnormalities (e.g fibroids, partial septate uterus)
Fetal abnormalities
Placenta praevia
Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

Face the patient’s head
Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

Breech – attempt ECV before labour, vaginal breech delivery or C-section
Brow – a C-section is necessary
If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
If the chin is posterior (mento-posterior) then a C-section is necessary
Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

Breech - attempt ECV before labour, vaginal breech delivery or C-section

Found an error? Is our article missing some key information? Make the changes yourself here!

Once you've finished editing, click 'Submit for Review', and your changes will be reviewed by our team before publishing on the site.

We use cookies to improve your experience on our site and to show you relevant advertising. To find out more, read our privacy policy .

Privacy Overview

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android . Learn more here!

Remote Access
Save figures into PowerPoint
Download tables as PDFs

OB/GYN Hospital Medicine: Principles and Practice

Chapter 63: External Cephalic Version

Joshua I. Rosenbloom; Shayna N. Conner

Download Chapter PDF

Disclaimer: These citations have been automatically generated based on the information we have and it may not be 100% accurate. Please consult the latest official manual style if you have any questions regarding the format accuracy.

Download citation file:

Search Book

Jump to a Section

Introduction, anatomy, physiology, and pathophysiology, indications.

CONTRAINDICATIONS
INFORMED CONSENT
THE PROCEDURE
Full Chapter
Supplementary Content

What are the indications and contraindications to external cephalic version (ECV)?

What are the success rates of ECV?

What are the key steps to the procedure?

What are the risks associated with ECV?

Mrs. Smith is a 27-y.o. G2P0010 at 37 0/7 weeks gestation who was sent to you by her primary obstetrician for ECV after discovery of breech presentation at her 36-week appointment. The patient has many questions regarding the intended procedure, and as the OB/GYN hospitalist who will be performing the ECV, you must be prepared to answer her.

Malpresentation (i.e. noncephalic presentation) complicates approximately 5% of pregnancies at term. 1 Diagnosis is typically made by ultrasound, preferably before the onset of labor. Although abdominal palpation or vaginal exam may suggest malpresentation, the diagnosis should be confirmed by ultrasound. The American College of Obstetricians and Gynecologists (ACOG) recommends documentation of fetal presentation starting at 36 weeks gestation. 2 If malpresentation is identified and no contraindications exist, the obstetrician should offer the patient ECV and counsel her on the risks and benefits of the procedure. In ECV, the obstetrician attempts to turn the fetus manually into a cephalic presentation. ACOG has recently published a Practice Bulletin that summarizes the major points and evidence with regard to ECV. 2

Breech presentation occurs in 3% to 4% of labors. 1 It is more common earlier in gestation, with 25% of pregnancies <28 weeks and 7% of pregnancies at 32 weeks being complicated by breech presentation. 1 There are three types of breech presentation: frank, complete, and incomplete (also known as footling ) ( Fig. 63-1 ). Factors associated with breech presentation include such fetal malformations as trisomies, prematurity, müllerian anomalies, and fundal placentation. 1 As experience with breech vaginal deliveries ( Chapter 59 ) is declining, most women with a breech fetus deliver by cesarean section (C-section) ( Chapter 60 ). Alternatively, ECV may be employed to turn the fetus and permit a vaginal delivery. Of note, ECV also should be offered in cases of transverse and oblique lies, and it has a higher success rate in these circumstances than in breech presentation. 2

FIGURE 63-1.

Types of Breech Presentation. A. Complete breech. B. Frank breech. C. Incomplete, or footling breech. (Reproduced with permission from Posner G, Dy J, Black A, et al: Oxorn-Foote Human Labor & Birth, 6th ed. New York, NY: McGraw-Hill Companies, Inc; 2013.)

An image shows different types of Breech Presentation. Figure A shows Incomplete or footling breech. Figure B shows Complete breech. And Figure C shows Frank breech.

All women with singleton fetuses in nonvertex presentations at term should be offered a trial of ECV unless contraindications exist. Box 63-1 lists the indications for ECV.

Singleton intrauterine pregnancy with malpresentation

No contraindication to vaginal delivery (e.g. placenta previa)

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.

Please Wait

King Edward Memorial Hospital Obstetrics & Gynaecology

CLINICAL PRACTICE GUIDELINE Abnormalities of Lie / Presentation This document should be read in conjunction with the Disclaimer

Contents Breech presentation ...... 2 Antenatal management ...... 3 External cephalic version ...... 4 Elective caesarean section ...... 4 Undiagnosed breech presenting in labour ...... 4 Diagnosed breech booked for caesarean presenting in labour ...... 5 Criteria recommended for a planned vaginal breech term birth ...... 5 Pre-term breech – Vaginal birth ...... 5 External cephalic version quick reference guide (QRG) ...... 6 Flow chart for external cephalic version ...... 7 External cephalic version ...... 8 Background information ...... 8 Key points ...... 8 Contra-indications to performing an ECV ...... 8 Procedure ...... 9 Breech presentation: Planned vaginal birth QRG ...... 11 Breech labour and birth flowchart ...... 13 Planned vaginal breech birth ...... 14 Unstable lie at or near term ...... 19 Antenatal management ...... 19 Birth management options ...... 20 Birth management for a woman in labour with an unstable lie ...... 20 Rare presentations ...... 21

References ...... 22

Page 1 of 24 Abnormalities of Lie / Presentation

Breech presentation Background Breech presentation occurs in 3% to 4% of pregnancies at term.1 The randomised multicentre Term Breech Trial (TBT) showed that a planned elective caesarean section (ELUSCS) reduces the risk for adverse perinatal outcomes or serious maternal morbidity when compared to a planned vaginal breech birth in the short term.1, 7 Long term follow-up at 2 years has not found neonatal neurological outcomes or maternal outcomes differing between women who had an ELUSCS compared to vaginal breech birth.4, 5 A large study conducted in the Netherlands following the TBT study found that the rapid increase in caesarean section rates resulted in substantial improvements in perinatal outcomes leading to halving of perinatal mortality rates, and ever greater reductions in the incidence of perinatal birth trauma .2, 8 However, the view remains that if the application of strict criteria before and during labour is met; planned vaginal birth of a singleton breech at term is a reasonable management option.1, 9 External cephalic version (ECV) from 36 weeks has been shown to decrease the incidence of breech presentation at term and consequently reduce the ELUSCS rates.2, 10 It is seen as a safe procedure provided it is performed in a setting where caesarean section can be performed if necessary. A meta-analysis looking at risk for performing an ECV indicates that fetal death risk is 1 per 5000 procedures; pooled complications risk was 6.1%, and risk for requiring caesarean was 0.35%.11 However, a large cohort study found that performing an ECV may carry a higher risk for caesarean section of 0.5%.1, 12 A recent large multi-centre randomised study found that ECV initiated at 34-35 weeks gestation compared with 37 weeks or more increases the probability of cephalic presentation at birth, however it does not reduce rate of caesarean sections, and it may increase the risk rate for preterm birth .13

Key points 1. ELUSCS for a singleton breech at term has been shown to reduce perinatal or neonatal mortality rates and serious neonatal morbidity rate in the first 6 weeks of life.2, 7 2. Long-term follow-up at 2 years showed neurological infant outcomes do not differ by planned mode of birth even in the presence of serious short term neonatal morbidity.2 3. ELUSCS is not associated with substantially better or worst outcomes for women 2 years after birth when compared to planned vaginal singleton breech birth at term.4, 5 4. All women with a singleton breech presentation with no contra-indications to the procedure should be offered an ECV. Success rates for ECV are approximately 40% in nulliparous women and 60% in multipara women.3

Obstetrics & Gynaecology Page 2 of 24 Abnormalities of Lie / Presentation

5. A woman attending a low-risk midwifery antenatal clinic, and who is found to have a breech presentation at 35-36 weeks gestation shall be referred for obstetric medical review prior to 37 weeks gestation. 6. If breech diagnosis is made after 37 weeks, obstetric review / counselling is required, and an ultrasound should be performed to assess for fetal or maternal causes of the malpresentation, and fetal growth / wellbeing.1 7. Careful case selection and labour management in a modern obstetric setting may achieve a level of safety similar to ELUSCS.2 Planned vaginal singleton breech birth is an option for women who have no maternal or fetal contra-indications to this mode of birth. Women who meet the criteria for a planned vaginal breech birth who develop complications which are contraindications to a planned term breech birth, must be referred to the team consultant for review and counselling on the day. If after hours or the consultant is not available the woman must be referred to MFAU/Labour and Birth Suite, for review by the Senior Registrar. 8. The Consultant / Senior Registrar must have an informed discussion with the woman (and her support person if available) including options, recommendations and the possible outcomes. 9. This conversation and the final decision should be clearly documented in the notes by the medical officer with the appropriate level of seniority undertaking the counselling. 10. The mode of birth for preterm breech presentation is made based according to individual clinical situations, and the decision is made after discussion with the team Consultant and the woman.

Antenatal management Breech presentation may require different options for management:  ECV  Elective caesarean section  Planned breech vaginal birth  Antenatally undiagnosed breech presentation presenting in labour 1. Refer women with a breech presentation between 35-36 weeks gestation for medical obstetric review as near as possible to 36 weeks gestation. 2. If there are no contra-indications the woman should be offered an ECV1 between 36-37 weeks gestation. An ECV at 34-36 may be performed with Consultant approval and the woman should be advised of the risk for preterm birth associated with performing ECV at this gestation. ECV may be attempted after 37 weeks if the diagnosis is delayed, albeit with a lower success rate. 3. Prior to booking an ECV, explanation about the procedure shall be given including risks, side-effects, and outcomes. Note: An ECV is inappropriate if a caesarean is indicated for other reasons.1

Obstetrics & Gynaecology Page 3 of 24

Abnormalities of Lie / Presentation

4. Ultrasound examination should be performed to assess presentation (type of breech, exclude hyperflexion of the head), placental location, amniotic fluid volume and to exclude any fetal and uterine anomalies.1 5. The procedure is performed in the Maternal Fetal Assessment Unit (MFAU). 6. Depending on the maternal decision regarding mode of birth, obtain written consent14:  For a Non-Elective Caesarean on the MR295: ‘Generic consent form’ bearing in mind that it is not possible to confirm the nature of the uterine incision prior to commencement of surgery, especially in the setting of fetal malpresentation.  ECV on the MR 295.75: ‘Consent form for External Cephalic Version’  See sections in this document: External Cephalic Version for detailed information about the procedure and contraindications.

External cephalic version ECV for uncomplicated term breech presentation should be offered to nulliparous women from 36 weeks gestation and for multiparous women from 37 weeks gestation if there are no contra-indications to the procedure. See:  Sections in this document: External Cephalic Version for detailed information about the procedure and contraindications and ECV- MFAU – Quick Reference Guide.

Elective caesarean section Caesarean section should be booked for women who elect this mode of birth. A woman whose only indication for CS is breech presentation, should not be transferred to the theatre suite until the presentation has been confirmed with bedside ultrasound by a WNHS credentialed practitioner.

Undiagnosed breech presenting in labour The decision regarding mode of birth will depend on gestation, stage of labour or imminent birth, maternal and fetal risks, and parental wishes after consultation with the obstetric team.1 An intrapartum ultrasound should be performed if possible.1 Following counselling and ensuring the criteria are met for a vaginal breech birth, a woman may choose this option of birth.1 However, it should be stated here that a woman may choose her method of birth, regardless of risks. If the diagnosis of breech presentation is made in advanced labour, the lack of opportunity to assess for contraindications for vaginal breech birth may increase the risk of adverse perinatal outcomes. However, this risk should be balanced against the risk of difficult caesarean section at advanced cervical dilatation when decisions regarding the appropriate mode of birth are made.

Obstetrics & Gynaecology Page 4 of 24

Diagnosed breech booked for caesarean presenting in labour The management plan may be adjusted depending on the gestation, clinical situation and consultation with the woman and her obstetric team. Proceed to Caesarean section if breech presentation is verified, only if the woman confirms her request for this mode of birth.

Criteria recommended for a planned vaginal breech term birth

 The woman has completed a consent form after counselling regarding risks and outcomes of a breech birth compared to an elective caesarean section.1  Availability of a consultant obstetrician trained in breech delivery for the entire labour process, including arrangements for shift changes & fatigue.  The woman should have a clinically adequate pelvis .1-4  Exclusion of a growth restricted fetus2, 3 or macrosomia2, 4, 5 Estimated fetal weight is between 2500g and 3800g3, 6  Exclusion of a footling or kneeling breech. The breech should be in the frank or complete breech position .1  The fetus has a flexed head1, 3  Immediate theatre facilities should be available for caesarean section if required, including skilled anaesthetic staff & neonatal resuscitation facilities.1  No previous caesarean section.  No fetal anomaly incompatible with vaginal birth2, 3  Absence of fetal or maternal compromise  Continuous fetal heart rate monitoring during labour.3  Spontaneous onset of labour. Note: For criteria and management of a vaginal breech birth see sections in this document: Breech – Vaginal Birth Management and Breech Vaginal Birth QRG

Pre-term breech – Vaginal birth The mode of birth is decided by the woman and the Obstetric team following discussion based on individual circumstances.3

Obstetrics & Gynaecology Page 5 of 24 Abnormalities of Lie / Presentation

External cephalic version quick reference guide (QRG) Medical and midwifery staff should be familiar with the contents of the full guideline.

Criteria for referral A woman with a breech presentation ≥ 36 weeks gestation, who has been counselled about the procedure has a written maternal consent document in the medical records. Prior to the procedure 1. Check a written consent is completed on the MR 295.75 2. Record maternal baseline observations for pulse, respirations and BP. 3. Perform a CTG for 20 minutes, or cease earlier if the CTG meets the definition of normal prior to 20 minutes. 4. Check a formal ultrasound has been performed within 24 hours of the procedure. Ensure the presentation is still breech by use of the real time scanner. 5. Confirm the Medical Officer performing the procedure is available in 30 minutes before administering the prescribed 150mg oral Ranitidine and subcutaneous Terbutaline 0.25mg (250mcg). 6. Following administration of tocolysis monitor the maternal pulse, BP, and the FHR 10 minutely until the ECV is performed. 7. Perform the ECV 30 minutes after tocolysis, or when maternal pulse is >100bpm. Post procedure - whether successful or not 1. Monitor the FHR by CTG for 40 minutes. 2. Monitor the maternal pulse, BP, vaginal loss, and pain 15 minutely for 30 minutes. 3. If the mother is Rhesus negative, obtain blood for a Group and Antibody screen (Kleihauer), then administer Anti-D as required. 4. Discharge the woman home after 1 hour provided:  Maternal observations are normal  There is a normal CTG. See KEMH clinical guideline: O&G: Fetal Surveillance: Fetal Heart Rate Monitoring  There are no signs of labour, abnormal vaginal loss, or abdominal pain  The medical team is satisfied with the maternal fetal condition 5. Instruct the woman to contact the hospital, and come in if any of these abnormalities occur.

Obstetrics & Gynaecology Page 6 of 24 Abnormalities of Lie / Presentation

Flow chart for external cephalic version

Woman presents to the Maternal Fetal Assessment Unit for ECV

Midwife ensures the woman has a signed consent form

Midwife performs maternal observations and arranges ultrasound assessment if not done in the last 24 hours

Does NO ultrasound reveal YES contraindications to ECV?

Commence FHR monitoring via CTG

NO Inform Obstetric Is CTG reactive? Registrar

Administer antacid and tocolytic as prescribed. Obstetrician to perform ECV 30 minutes after tocolysis or when maternal pulse >100

Following ECV (whether successful or not): • perform a CTG and maternal assessments and • arrange Kleihauer and anti-D for the Rh negative woman

YES NO Is CTG reactive after 40 mins with no sinister features?

Arrange USS for biophysical profile and Obstetric Registrar review Was ECV NO successful?

Arrange for Obstetric Registrar to discuss mode of birth with the woman YES

If the woman is uncertain If the woman elects for Return to routine If the woman elects for about mode of birth arrange a trial of vaginal birth antenatal care with Caesarean section arrange a review with referring team or arrange review with referring team or clinic date for elective C/S at clinic at the next available referring team in one within one week 39 weeks appointment week

Obstetrics & Gynaecology Page 7 of 24 Abnormalities of Lie / Presentation

External cephalic version Background information Performing an external cephalic version (ECV) has been shown to reduce the rate of non-cephalic presentations at term thereby reducing the number of caesarean sections for breech birth at term.10, 15 Additionally, there is currently insufficient evidence on the effect of other techniques, such as maternal positioning and moxibustion, for breech version.16 Spontaneous version rates for nulliparous women are approximately 8% after 36 weeks gestation, and only 5% after an unsuccessful ECV. If a successful ECV is done, spontaneous reversion will occur in 5% of cases. Risk for complications following ECV include abnormal cardiotocograph (CTG) patterns which may be uncomplicated and transient or pathological17, bleeding which may be asymptomatic (e.g. fetomaternal transfusion, abruption)17, 18, cord complications17, 18, ruptured membranes18, and fetal mortality17. A recent large multi-centre randomised study found that ECV initiated at 34-35 weeks gestation compared with 37 weeks or more increases the probability of cephalic presentation at birth, however it does not reduce the rate of caesarean section, and it may increase the risk rate for preterm birth.13

Key points 1. ECV should be offered from 36 weeks gestation for nulliparous women and 37 weeks for multiparous women with uncomplicated breech presentations and no contra-indications to the procedure.19 ECV is not appropriate if a caesarean is indicated for other reasons.20 2. The success rates for ECV are approximately 40% in nulliparous women and 60% in multipara.20 3. Spontaneous reversion to breech presentation after successful ECV occurs in less than 5% of women.19 4. ECV has low complications rates with approximately 0.5% requiring caesarean section.20, 21 5. Women who have a successful ECV have a higher risk of requiring a caesarean section in labour compared to other women.22 6. Tocolysis used to relax uterine muscles increases the success rate of a ECV.15, 19 7. Women who are Rhesus negative will require a blood group and anti-body screen (Kleihauer) after the ECV is performed, and Anti-D administered.

Contra-indications to performing an ECV

Absolute contra-indications  Where caesarean section (CS) is indicated19, 20 e.g. placenta praevia13, previous classical CS13

Obstetrics & Gynaecology Page 8 of 24 Abnormalities of Lie / Presentation

 Abnormal CTG19; fetal heart rate abnormalities13  Ruptured membranes13, 19f  Contracted pelvis  Fetal death  Placental abruption13

Relative contra-indications  Small-for-gestational-age fetus with abnormal Doppler parameters19; Fetal hypoxia20  Pre- eclampsia with proteinuria19; or Antepartum haemorrhage20 in the last week19  Major fetal anomalies19, 20; Unstable lie19; Multiple pregnancy19, 20  A restrictive nuchal cord20, Hyper-extended head13, 20  Major uterine anomaly13, 19, 20; Scarred uterus19, 20  Oligohydramnios13, 20 or hydramnios13

Procedure Prior to the procedure 1. Ensure the woman has received counselling about risks, benefits, and outcomes associated with performing an ECV. The MR 295.75: Consent form for ECV must be signed before commencing the procedure. 2. Check there are no contra-indications to performing an ECV. 3. A formal ultrasound assessment for fetal presentation, placental location, amniotic fluid volume and assessment for fetal or uterine anomalies must be performed 24 hours prior to the procedure. 4. Perform a CTG for 20 minutes (or less if a normal trace is obtained in a shorter time) prior to the procedure. 5. Complete a portable ultrasound prior to commencing preparation for the procedure to ensure the fetus is still in the breech presentation. 6. Perform baseline maternal observations of pulse, respirations, and blood pressure (BP). Then monitor the maternal pulse, BP, and fetal heart rate (FHR) every 10 minutes after tocolysis is given until the ECV commences. 7. Arrange written orders for oral Ranitidine 150mg and subcutaneous Terbutaline 0.25mg (250mcg). 8. Ensure the Obstetrician or Medical Officer performing the procedure will be available to perform the procedure in 30 minutes time before administering the prescribed anti-emetic and tocolytic. 9. Commence the ECV 30 minutes after tocolysis, or when the maternal pulse is >100bpm.

Obstetrics & Gynaecology Page 9 of 24 Abnormalities of Lie / Presentation

Procedure 1. Ensure the woman has emptied her bladder. 2. Position the woman in a recumbent position (a wedge placed under her buttocks). 3. Lubricate the maternal abdomen using mineral oil, ultrasonic gel, or talcum powder. This decreases friction which may reduce maternal discomfort. 4. Place your hands between the fetal breech and the maternal symphysis pubis. 5. Dislodge the breech from the maternal pelvis. 6. After the breech is dislodged, guide the fetal head in a forward or backward roll toward the maternal pelvis while simultaneously guiding the breech towards the fundus. 7. If the forward roll is unsuccessful an alternative approach, the backward flip can be attempted. 8. Abandon the procedure if:  attempts at a forward roll or a backward flip are unsuccessful  more than 5 minutes of uterine pressure is required  there is maternal intolerance to the procedure  there is evidence of an abnormal FHR using sonography. Post procedure Regardless of whether the ECV is successful or not: 1. Monitor the FHR by CTG for 40 minutes. A normal CTG must be achieved prior to discharge. 2. Monitor and record the maternal pulse, BP, and vaginal loss 15 minutely for 30 minutes. 3. Obtain a blood group and antibody screen sample for a Kleihauer test and arrange prophylactic Anti-D administration if the maternal blood group is Rhesus negative. 4. Women may be discharged home after 1 hour provided:  The maternal observations are normal  The CTG is normal  The obstetric team is satisfied with the fetal and maternal condition. 5. Instruct the woman to phone or return to the hospital if any of the following occur:  Vaginal bleeding  Rupture of membranes  Commencement of labour

Obstetrics & Gynaecology Page 10 of 24

 Change in pattern or decreased fetal movements  Abnormal abdominal pain. 6. Ensure an antenatal clinic appointment is made for obstetric medical review in 1 week to assess for spontaneous reversion.

Breech presentation: Planned vaginal birth QRG This QRG is to be read in conjunction with the full details in this document. Medical and midwifery staff should be familiar with the contents of the full guideline. NB: Women planning a breech birth who develop complications which are contraindications to a planned term breech birth must be referred for review by the team consultant. If the consultant is unavailable or after hours, the woman must be reviewed in MFAU / Labour and Birth Suite by the Senior Registrar. The Consultant / Senior Registrar must have an informed discussion with the woman (and her support person if available) including options, recommendations and the possible outcomes. This conversation and the final decision should be clearly documented in the notes by the medical officer with the appropriate level of seniority undertaking the counselling.

NOTE 1: DEFINITION OF UNCOMPLICATED BREECH  Flexed or extended legs  37-42 weeks gestation  No evidence of cephalopelvic disproportion (CPD)1  Clinical estimation of fetus >2.5kg and < 3.8kg  Well flexed head1  No anticipated mechanical difficulty NOTE 2: PROGRESS OF LABOUR  Cervical dilatation of 1cm per hour regardless of parity  In second stage – should be progressive descent of the buttocks through the pelvis, and the breech should be on the pelvic floor within 1 hour of full dilatation, even in the absence of active pushing.

Obstetrics & Gynaecology Page 11 of 24

NOTE 3: LABOUR RECOMMENDATIONS  Inform the Obstetric Consultant at the onset of labour, and when the woman’s cervix is fully dilated.  Notify the paediatrician at the onset of labour, and arrange also to be present at the birth.  Continuous fetal monitoring1  Availability of facilities to perform a caesarean section.1  Arrange additional equipment – e.g. breech towel, lithotomy stirrups.  Confirm the cervix is fully dilated prior to pushing to ensure the woman does not have a premature urge to push.  When fully dilated the women should not be encouraged to actively push until she has a strong urge to do so, or the buttocks are on view.  Birth should be imminent after 1 hour of active pushing in a nullipara, and after ½ hour of active pushing for a multipara.  Consider urinary catheterisation prior to birth.  Controlled and gentle birth of the neonate’s head:  Maurice Smellie-Veit grip (or adaptations for active birth positions)  Forceps to the after-coming head  No breech extraction Do not administer third stage oxytocic until after the breech birth is completed i.e. until the head is delivered.

Obstetrics & Gynaecology Page 12 of 24

Breech labour and birth flowchart

Woman in labour with uncomplicated breech presentation Note 1

Obstetric registrar or above informed and management plan discussed

NO Advanced YES Known breech? labour/birth imminent? Note 3 NO YES • Review contraindications • Discuss options NO Planned vaginal • Informed choice and birth? consent Note 3 YES

NO Satisfactory progress? Note 2

Discuss with Continue with Consultant documented birth Obstetrician re further plan management

NO Fully YES dilated, breech on perineum?

Vaginal birth with Caesarean section birth with consultant present US prior to transfer to theatre Note 3

Obstetrics & Gynaecology Page 13 of 24

Planned vaginal breech birth Background information Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity compared to birth by elective caesarean section23, however study of long term follow-up at 2 years found that the neonatal neurological outcomes did not differ between either mode of birth even in the presence of serious short-term morbidity.2 Complications of vaginal breech birth include Erb’s palsy, fractures to the clavicle, humerus or femur, and dislocation of the hips or shoulders. Trauma to the abdominal structures may occur if the fetal abdomen is grasped incorrectly, some bruising may be noted especially to male genitalia,24 and other complications such as cerebral haemorrhage or fractures, or spinal cord injury are additional risks.23 Key points 1. Planned term vaginal breech birth is a reasonable option provided there are no fetal or maternal contra-indications and the strict criteria is followed. The presence of an Obstetrician competent in breech birth and facilities for immediate caesarean section are required25. 2. Women planning a breech birth who develop complications which are contraindications to a planned breech birth must be referred for review by the team consultant. If the consultant is unavailable or after hours, the woman must be reviewed in MFAU / Labour and Birth Suite by the Senior Registrar. The Consultant / Senior Registrar must have discussions with the woman and the junior medical staff. 3. The Consultant / Senior Registrar must have an informed discussion with the woman (and her support person if available) including options, recommendations and the possible outcomes. 4. This conversation and the final decision should be clearly documented in the notes by the medical officer with the appropriate level of seniority undertaking the counselling. 5. The Consultant Obstetrician is informed at the onset of labour, when the woman’s cervix is fully dilated, and if there are concerns with maternal-fetal wellbeing or labour progress 6. The paediatric team is informed at the onset of labour, and should be present for the birth as per KEMH Clinical Guideline, O&G: Labour & Birth: Paediatric Team Attendance for ‘At Risk’ Births - LBS QRG 7. Clinical pelvic examination should be performed to assess pelvic adequacy when assessing suitability for vaginal breech birth. 8. Induction of labour is not recommended and is considered non-standard management2.

Obstetrics & Gynaecology Page 14 of 24

9. Augmentation of labour is not recommended but may be appropriate in the presence of uterine dystocia provided the consultant obstetrician is confident there is no fetopelvic disproportion2, 23. 10. Continuous CTG monitoring during labour should be performed25. 11. A vaginal examination should be performed if rupture of membranes occurs2, or to confirm full dilatation prior to a woman pushing, ensuring she does not have a premature urge to push. 12. Cervical dilatation during active labour should occur at a rate of at least 1cm per hour. 13. The woman should not be encouraged to actively push until the breech has reached the pelvic floor and she has a strong urge, or the buttocks are on view. 14. If birth is not imminent after 1 hour of active pushing for a nullipara woman, or ½ hour for a multipara woman, a caesarean section should be initiated. 15. Breech extraction is not recommended during the breech birth of a singleton fetus. 16. Third stage oxytocic should not be administered until the fetal head is delivered.

Definition of an uncomplicated breech presentation  Flexed or extended fetal legs.  37-42 weeks (women should be advised of risks associated with prolonged pregnancy ).  No evidence of cephalopelvic disproportion (CPD).  Clinical estimation of the fetus >2.5kg or < 3.8kg.  Well flexed head.  No anticipated pelvic obstruction to birth. On admission – management for women in labour 1. Confirm the fetal presentation as flexed or extended breech of uncomplicated term breech and exclude contra-indications for vaginal breech birth by ultrasound. 2. Inform the Consultant Obstetrician. 3. Notify the paediatric team. 4. Commence CTG for continuous fetal heart rate monitoring. 5. Perform a digital vaginal examination to assess progress, and exclude cord presentation / prolapse. 6. Collect blood for a group and hold.

See the following two pages for planned vaginal breech management in the first stage and second stage of labour.

Obstetrics & Gynaecology Page 15 of 24

Flow chart – Planned term singleton vaginal breech birth See section in this document: Breech Vaginal Birth – Quick Reference Guide

First stage management Care is the same as in cephalic presentation, with some additional care for the management of an uncomplicated term breech presentation. Action MANAGEMENT IN FIRST STAGE ADDITIONAL INFORMATION

Monitoring labour Cervical dilation should be 1cm The Consultant progress per hour from 4cm for all women Obstetrician should be regardless of parity. advised of any delay in progress. In the absence of adequate progress in labour, caesarean section is recommended.

Augmentation Not normally considered, however Poor progress may be a may be only used in individualised risk factor for difficulty special circumstances for uterine with birth of the after dystocia26 if there is no clinical coming head3. suspicion of CPD. The decision for Intact membranes use is only made with consultant prevent risk for cord obstetrician approval. prolapse and artificial rupture of membranes is not recommended24.

Fetal Surveillance Continuous CTG25

Vaginal  With spontaneous rupture of Excludes cord Examination membranes prolapse27.  To confirm full dilatation if a This confirms full woman has an urge to push. dilatation of the cervix in  Monitor routine progress of the event of an urge to labour and more frequently as push. the situation requires.

Analgesia The woman to choose her preferred method of analgesia. An epidural may be an option if the woman has a premature urge to push18.

Bladder Monitor 1-2 hourly A full bladder may Management impede descent of the breech.

Hydration Fasting in not routinely required. Confirm with obstetric Confirm medical recommendation. team hydration management.

Obstetrics & Gynaecology Page 16 of 24

Action MANAGEMENT IN FIRST STAGE ADDITIONAL INFORMATION

Maternal An upright position can be An upright position may Positioning encouraged18. aid the descent of the 27 breech .

Additional  Availability of the real time Equipment ultrasound machine

Medical Notify the Consultant Obstetrician: notifications  At full dilatation  If poor progress of labour  If concerns of maternal-fetal wellbeing

Second Stage Management Action MANAGEMENT IN SECOND ADDITIONAL STAGE INFORMATION

Confirm second Perform a vaginal examination to Confirms that the woman stage confirm full dilatation prior to is able to push if she has pushing. the urge.

Pushing Encourage active pushing when the woman has a strong urge, or the buttocks are on view.

Monitoring progress Birth should be imminent after one The consultant hour of active pushing in a obstetrician should be nullipara, and after ½ hour for a immediately notified of multipara. any delay in progress. In the absence of adequate progress in second stage, caesarean section is recommended3. Fetal Surveillance Continuous CTG25

Bladder Consider urinary catheterisation Management prior to birth if the bladder is not emptied.

Position for birth Dorsal or lithotomy Following maternal consent the practitioner should utilise the maternal position with which they are familiar3.

Obstetrics & Gynaecology Page 17 of 24

Action MANAGEMENT IN SECOND ADDITIONAL STAGE INFORMATION

Equipment  Breech towel (warmed)  Lithotomy stirrups if necessary  Neville-Barnes’ and Wrigley’s Forceps immediately available Analgesia As indicated.

Episiotomy Not routine – should be performed when indicated to facilitate birth3.

Birth principles  No breech extraction Can cause extension of  Traction/ fetal breech the head and nuchal displacement of the manoeuvres on breech are to 27 be avoided unless necessary arms. to expedite birth of a partially expelled fetus in a timely fashion.  Gentle suprapubic pressure 3 may aid flexion of the head .  Do not handle / manipulate May cause spasm of the the cord. cord18.  Extended arms may be delivered by the Løvset 2, 18 manoeuvre. Nuchal arms may be reduced with reverse Løvsets. Rapid birth of the head  Aftercoming head may be can cause sudden delivered spontaneously, with compression and risk for forceps, or by the Mariceau- tentorium cerebelli tear.24 Smellie-Veit manoeuvre.

Preserves warmth and  A small towel wrapped around provides a grip on the the fetal hips is useful. skin. Paediatrician Contact the paediatric team to be present for the birth.

Oxytocin for 3rd Withhold until the head is born. stage

Obstetrics & Gynaecology Page 18 of 24

Unstable lie at or near term Background An unstable lie is when the fetal presentation repeatedly changes beyond 36 weeks gestation.28 It is more common in parous women. Maternal causes include high parity, placenta praevia , pelvic contracture, uterine malformations,28 pelvic tumours, and a distended maternal urinary bladder. Fetal causes of unstable lie include polyhydramnios ,28 oligohydramnios , multiple pregnancy28, fetal macrosomia, and fetal abnormalities (e.g. hydrocephaly, abdominal distension, fetal death28).29 If the membranes rupture when there is an unstable lie, regardless of whether the woman is contracting there is significant risk for cord prolapse, especially if the lie is oblique or transverse, or if the presenting part is high above the pelvic inlet. If lie is not longitudinal when labour commences a compound presentation may result, or the pelvis may remain empty which can lead to fetal distress and other complications.29

Key points 1. The Obstetric Team Consultant shall be advised of all women with an unstable lie at or near term. 2. A management plan shall be formulated and documented on the ‘MR004 Obstetric Special Instruction Sheet’.

Antenatal management 1. If a woman is attending a low risk midwifery antenatal clinic and is found to have an unstable lie at term the midwife shall contact the team Consultant/Senior Registrar to discuss management. The next antenatal appointment needs to be with an obstetric medical antenatal team. 2. Investigate for causes of unstable lie. Ultrasound assessment may be required.28, 30 3. Conduct clinical assessment for the size of the fetus and the pelvis. Ultrasound assessment may be required in addition. 4. Formulate a plan for the mode of birth, and document on the MR004 Obstetric Special Instruction Sheet. 5. Advise the woman to contact the hospital if she commences labour, or has spontaneous rupture of membranes (SROM). 6. Inform the woman about risks of cord prolapse and management if this occurs at home or in the hospital.28 7. Provide written advice for the woman (to be given to the St. Johns Ambulance crew) describing management in the event of spontaneous rupture of membranes.

Obstetrics & Gynaecology Page 19 of 24

Birth management options After discussion with the woman who has an unstable lie, one of the 3 birth options should be decided:  Elective Caesarean Section  Expectant management – if no contraindications, await onset of labour  Active management – perform external version of the fetus to longitudinal lie and then commence an induction of labour.

1. If a woman lives a long distance from the hospital, admission28 at 38-39 weeks gestation – allows daily observation of lie and presentation and availability of immediate assistance should SROM, cord prolapse, fetal distress, or labour occur.29, 30 2. If spontaneous resolution to a longitudinal cephalic lie eventuates management options include:  a presentation which remains cephalic for 48 hours may be discharged home after review by the team Consultant and await spontaneous labour29  induce labour following team Consultant review.29 3. If the lie remains unstable, a stabilising induction may be an option28, 30 after review by the team Consultant. Birth management for a woman in labour with an unstable lie On admission  Perform a palpation.  Auscultate the fetal heart rate  Assess for SROM  Inform the obstetric medical team including the Senior Registrar

Labour management  ECV may be performed in early labour provided there are no contra- indications. A stabilising / controlled artificial rupture of the membranes (ARM) may then be performed.28 Note: Prior to controlled ARM, the woman should have an empty rectum and bladder, as these can interfere with the descent of the presenting part.28  Assess the presentation, lie and descent of the fetus frequently28 until the presenting part is well into the pelvis.  If SROM occurs perform a vaginal examination (VE) to exclude cord prolapse or malpresentation.  Conduct continuous fetal heart rate monitoring in labour.

Obstetrics & Gynaecology Page 20 of 24

 Obtain intravenous access and take blood for a full blood count, group and hold- the woman is at increased risk for caesarean section, and possible post- partum haemorrhage particularly if polyhydramnios is present.

Rare presentations Aim  To provide guidance on the appropriate consultation and management of malpresentations at KEMH.

Key points 1. Rare presentations (malpresentations) of the fetus include the following  Face presentation  Brow presentation  Compound presentation  Shoulder presentation  Oblique lie

2. Breech presentation- a consultant is to attend any viable vaginal breech birth. See Breech Presentation above. 3. If a woman is suspected to have a malpresentation antenatally, it must be discussed with the team consultant. 4. Management of unstable lie at term shall be discussed with the team consultant. 5. The team obstetrician, senior registrar and registrar must be notified immediately of all malpresentations that present in labour.28 6. All malpresentations presenting in labour must be reviewed by a consultant

Obstetrics & Gynaecology Page 21 of 24

References 1. RANZCOG. C-Obs 11: College statement: Management of breech presentation at term2013. Available from: https://www.ranzcog.edu.au/college-statements-guidelines.html#obstetrics. 2. Society of Obstetricians and Gynaecologist of Canada. Vaginal delivery of breech presentation. Journal of Obstetric Gynaecology of Canada. 2009 (June):557-66. 3. Royal college of Obstetricians and Gynaecologists (RCOG). Management of Breech Presentation (Green-top Guideline No. 20b) 2017 [Available from: https://www.rcog.org.uk/en/guidelines-research- services/guidelines/gtg20b/. 4. Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, et al. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The international randomized term breech trial. Am J Obstet Gynecol. 2004;191(3):864-71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15467555. 5. Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191(3):917-27. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15467565. 6. Taillefer C, Dube J. Single breech at term: Two continents, two approaches. JOGC. 2010 (March):238- 43. 7. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356(9239):1375-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11052579. 8. Rietberg CC, Elferink-Stinkens PM, Visser GHA. The effect of the term breech trial on medical intervention behaviour and neonatal outcome in the Netherlands: An analysis of 35,453 term breech infants. BJOG: an International Journal of Obstetrics and Gynaecology. 2005;112:205-9. 9. Azria E, Le Meaux JP, Khoshnood B, Alexander S, Subtil D, Goffinet F, et al. Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery. Am J Obstet Gynecol. 2012;207(4):285 e1-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23021690. 10. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term (Review). Cochrane Database of Systematic Reviews. 2012 (10). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000083.pub2/pdf. 11. Grootscholten K, Kok M, Oei G, et al. External Cephalic Version-Related Risks A Meta-analysis. Obstetrics & Gynecology. 2008;112(5):1143-51. 12. Collins S, Ellaway P, Harrington D, et al. The complications of external cephalic version: results from 805 consecutive attempts. BJOG: An International Journal of Obstetrics and Gynaecology. 2007;114:636-38. 13. Hutton EK, Hannah ME, Ross SJ. The Early External Cephalic Version (ECV) 2 Trial: An international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG: an International Journal of Obstetrics and Gynaecology. 2011;118:564-77. 14. Department of Health Western Australia. Consent to treatment policy for the Western Australian Health System 20112011. Available from: http://www.health.wa.gov.au/circularsnew/attachments/564.pdf. 15. Cluver C, Gyte GM, Sinclair M, Dowswell T, Hofmeyr GJ. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015;2. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000184.pub4/pdf. 16. Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012;10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23076882. 17. Collaris RJ, Oei SG. External cephalic version: A safe procedure? A systematic review of version- related risks. Acta Obstetrics and Gynecology Scandanavia. 2004;83:511-8. 18. Coates T. Malpositions of the occiput and malpresentations. In: Fraser DM, Cooper MA, editors. Myles Textbook for Midwives . 15th ed. Sydney: Churchill Livingstone; 2009. p. 573-605. 19. Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the

Obstetrics & Gynaecology Page 22 of 24

incidence of breech presentation. Green-top Guideline No 20a. 2006. 20. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. C-Obs 11: College statement: Management of breech presentation at term2013. Available from: https://www.ranzcog.edu.au/college-statements-guidelines.html#obstetrics. 21. Collins S, Ellaway P, Harrington D, Pandit M, Impey LW. The complications of external cephalic version: Results from 805 consecutive attempts. BJOG. 2007;114(5):636-8. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2007.01271.x/pdf. 22. de Hundt M, Velzel J, de Groot CJ, Mol BW, Kok M. Mode of delivery after successful external cephalic version: A systematic review and meta-analysis. Obstet Gynecol. 2014;123(6):1327-34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24807332. 23. Hannah ME, Hannah WJ, Hewson SA, et al. Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomised multicentre trial. The Lancet. 2000;356:1375-83. 24. Thorogood C, Donaldson C. Disturbances in the rhythm of labour. Midwifery preparation for practice. 2nd ed. Sydney: Churchill Livingstones; 2010. p. 819-61. 25. Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). College Statement C Obs-11: Management of breech presentation at term 2016 [Available from: https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG- MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Management-of- breech-presentation-at-term-(C-Obs-11)-Review-July-2016.pdf?ext=.pdf. 26. Society of Obstetrics and Gynecology of Canada. SGOC Clinical Practice Guideline No. 256. Substance Use in Pregnancy. JOGC. 2011 (April ):367-84. 27. Lewis P. Malpositions and malpresentations. In: Macdonald S, Magill-Cuerden J, editors. Mayes' Midwifery. 14th ed. Sydney: Bailliere Tindall; 2011. p. 869-98. 28. Coates T. Malpositions of the occiput and malpresentations. In: Marshall J, Raynor M, editors. Myles textbook for midwives. 16th ed. Edinburgh: Churchill Livingstone Elsevier; 2014. p. 435-54. 29. Mackenzie IZ. Unstable lie, malpresentations and malpositions. In: James D, Steer PJ, Weiner CP, et al, editors. High Risk Pregnancy Management Options. 4th ed. Nottingham: Elsevier Saunders; 2011. p. 1123-37. 30. Baskett T, Calder A. Malpresentations. In: Baskett TF, Calder AA, Arulkumaran S, editors. Munro Kerr's operative obstetrics 12th ed. Edinburgh: Elsevier; 2014. p. 116-22.

Related policies WA Health Consent to Treatment Policy 2016

Related WNHS policies, procedures and guidelines Form: MR 295.75: Consent form for ECV KEMH O&G Clinical Guidelines:

 [Restricted Area Guideline]: Induction of Labour: Artificial Rupture of the Membranes (ARM) [access via Health point intranet]

 Fetal Surveillance: Fetal Heart Rate Monitoring

Obstetrics & Gynaecology Page 23 of 24 Abnormalities of Lie / Presentation

Keywords: breech, external cephalic version, ELUSCS, obstetric ultrasound, undiagnosed breech, planned breech birth, abnormal lie, unstable lie, transverse lie, oblique lie, high presenting part, polyhydramnios, fetal presentation, face presentation, brow presentation, rare presentation, compound presentation, shoulder presentation, oblique lie, unstable lie, breech presentation, ECV, external cephalic version, QRG, vaginal breech, presenting part Document owner: OGID Author / Reviewer: Head of Department- Obstetrics July 2018: Evidence on this topic was reviewed and overall guidance remains unchanged. Minor changes and formatting have been made. Date first issued: July 2018 Version 2 Supersedes: History: In July 2018 amalgamated seven individual guidelines on abnormalities of lie/presentation dating from March 2001. Supersedes: 1. Breech Presentation (dated Feb 2018) 2. Breech Presentation (Uncomplicated Term) - Planned Vaginal Birth (dated May 2017) 3. Breech (Uncomplicated Term) Vaginal Birth QRG (dated Feb 2018) 4. External Cephalic Version (ECV) (dated April 2015) 5. ECV: MFAU QRG (dated April 2015) 6. Rare Presentations (dated April 2015) 7. Unstable Lie at or Near Term (dated April 2015) Reviewed: July 2018; (amended Oct 2018; April 2021 (v2)) Next review date: July 2021 Endorsed by: MSMSC Date: 24/7/2018 NSQHS Standards 1 Governance, 4 Medication Safety; 8 Recognising & Responding to Acute (v2) applicable: Deterioration Printed or personally saved electronic copies of this document are considered uncontrolled. Access the current version from the WNHS website.

Obstetrics & Gynaecology Page 24 of 24

External Cephalic Version and Reducing the Incidence of Term Breech Presentation (Green-top Guideline No. 20a)

Access the PDF version of this guideline on Wiley
Access the web version of this guideline on Wiley

Summary: This guideline presents the best evidence concerning methods to prevent noncephalic presentation at delivery and therefore caesarean section and its sequalae. The mode and technique of delivering a breech presentation is summarised in the Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 20b Management of Breech Presentation .

Breech presentation, which complicates 3–4% of term deliveries, occurs most frequently in nulliparous women. Breech presentation is also more common in preterm deliveries. The publication of the Term Breech Trial led to the significant decrease in the number of women undergoing vaginal breech birth. Planned vaginal breech birth remains rare in the UK as in many countries and thus attempts to prevent breech presentation are important.

COVID disclaimer: This guideline was developed as part of the regular updates to programme of Green-top Guidelines, as outlined in our document Developing a Green-top Guideline: Guidance for developers , and prior to the emergence of COVID-19.

Version history: This is the second edition of this guideline.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests:

Mr M Griffiths is a member of Doctors for a Woman's right to Choose on Abortion. He is an unpaid member of a Quality Standards Advisory Committee at NICE, for which he does receive expenses for related travel, accommodation and meals.

Mr LWM Impey is Director of Oxford Fetal Medicine Ltd. and a member of the International Society of Ultrasound in Obstetrics and Gynecology. He also holds patents related to ultrasound processing, which are of no relevance to the Breech guidelines.

Professor DJ Murphy provides medicolegal expert opinions in Scotland and Ireland for which she is remunerated.

Dr LK Penna: None declared.

This page was last reviewed 16 March 2017.

Getting Pregnant
Registry Builder
Baby Products
Birth Clubs
See all in Community
Ovulation Calculator
How To Get Pregnant
How To Get Pregnant Fast
Ovulation Discharge
Implantation Bleeding
Ovulation Symptoms
Pregnancy Symptoms
Am I Pregnant?
Pregnancy Tests
See all in Getting Pregnant
Due Date Calculator
Pregnancy Week by Week
Pregnant Sex
Weight Gain Tracker
Signs of Labor
Morning Sickness
COVID Vaccine and Pregnancy
Fetal Weight Chart
Fetal Development
Pregnancy Discharge
Find Out Baby Gender
Chinese Gender Predictor
See all in Pregnancy
Baby Name Generator
Top Baby Names 2023
Top Baby Names 2024
How to Pick a Baby Name
Most Popular Baby Names
Baby Names by Letter
Gender Neutral Names
Unique Boy Names
Unique Girl Names
Top baby names by year
See all in Baby Names
Baby Development
Baby Feeding Guide
Newborn Sleep
When Babies Roll Over
First-Year Baby Costs Calculator
Postpartum Health
Baby Poop Chart
See all in Baby
Average Weight & Height
Autism Signs
Child Growth Chart
Night Terrors
Moving from Crib to Bed
Toddler Feeding Guide
Potty Training
Bathing and Grooming
See all in Toddler
Height Predictor
Potty Training: Boys
Potty training: Girls
How Much Sleep? (Ages 3+)
Ready for Preschool?
Thumb-Sucking
Gross Motor Skills
Napping (Ages 2 to 3)
See all in Child
Photos: Rashes & Skin Conditions
Symptom Checker
Vaccine Scheduler
Reducing a Fever
Acetaminophen Dosage Chart
Constipation in Babies
Ear Infection Symptoms
Head Lice 101
See all in Health
Second Pregnancy
Daycare Costs
Family Finance
Stay-At-Home Parents
Breastfeeding Positions
See all in Family
Baby Sleep Training
Preparing For Baby
My Custom Checklist
My Registries
Take the Quiz
Best Baby Products
Best Breast Pump
Best Convertible Car Seat
Best Infant Car Seat
Best Baby Bottle
Best Baby Monitor
Best Stroller
Best Diapers
Best Baby Carrier
Best Diaper Bag
Best Highchair
See all in Baby Products
Why Pregnant Belly Feels Tight
Early Signs of Twins
Teas During Pregnancy
Baby Head Circumference Chart
How Many Months Pregnant Am I
What is a Rainbow Baby
Braxton Hicks Contractions
HCG Levels By Week
When to Take a Pregnancy Test
Am I Pregnant
Why is Poop Green
Can Pregnant Women Eat Shrimp
Insemination
UTI During Pregnancy
Vitamin D Drops
Best Baby Forumla
Postpartum Depression
Low Progesterone During Pregnancy
Baby Shower
Baby Shower Games

Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

Was this article helpful?

What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

A newborn baby wrapped in a receiving blanket in the hospital.

How your twins’ fetal positions affect labor and delivery

illustration of twin babies head down in utero

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70. https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

Where to go next

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

Advanced Search
Journal List
v.5(1); 2015 Apr

Use of External Cephalic Version and Amnioreduction in the Delivery of a Fetal Demise with Macrocephaly Secondary to Massive Intracranial Teratoma

Matthew j. blitz.

1 Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Hofstra North Shore-LIJ School of Medicine, Manhasset, New York

Elizabeth Greeley

Hima tam tam, burton rochelson.

Introduction Congenital intracranial tumors are rare and often incidentally diagnosed on routine ultrasound. We report a case of a fetal demise with a massive intracranial teratoma at 25 weeks of gestation and the management of her delivery in the setting of macrocephaly, breech presentation, and polyhydramnios.

Case A 31-year-old G3P1011 woman at 25 weeks' gestation presented with a recent fetal demise and a fetal intracranial tumor first identified at 16 weeks' gestational age. The patient had declined termination of pregnancy. Biometry was consistent with 24 weeks' gestation, except for a head circumference of 394.4 mm consistent with 39 weeks' gestation. The fetus was in a breech presentation. An external cephalic version (ECV) was successfully performed under epidural anesthesia and an amnioreduction was then performed to stabilize the fetal position. Immediate induction of labor and vaginal delivery followed.

Discussion ECV and amnioreduction may help facilitate delivery in cases of fetal demise complicated by macrocephaly, malpresentation, and polyhydramnios.

Fetal brain tumors are exceedingly rare, accounting for 0.5 to 1.5% of all childhood brain tumors, with an estimated incidence of 1.1 to 3.4 per million live births. 1 Although partially dependent on location and histologic type, they are usually associated with a poor fetal prognosis. Early cesarean delivery or termination before viability, employing destructive operations when appropriate, may help avoid obstetric complications because of the cephalopelvic disproportion. Here, we present a case of a massive immature fetal intracranial teratoma with antenatal cranial perforation and the management of her delivery in the setting of macrocephaly, breech presentation, and polyhydramnios.

Case Report

A 31-year-old woman, G3P1011 at 16 weeks' gestational age was found to have a fetus with an intracranial mass on ultrasound. The lesion progressively grew with significant distortion of intracranial skull anatomy at 20 weeks. She was counseled at both visits regarding the dismal prognosis and was offered termination. At 25 2/7 weeks' gestational age, she presented for a maternal–fetal medicine consultation regarding the large fetal intracranial mass. Her history was remarkable for a previous first trimester elective termination followed by a term vaginal delivery. At the time of consultation, a fetal demise with hydrops was discovered on ultrasound. Fetal biometry was consistent with 24 weeks' gestational age based on long bone measurements, but the fetal head circumference was 394.4 mm consistent with 39 weeks' gestational age. An 8 × 10 cm heterogeneous intracranial mass ( Fig. 1 ) was identified and the fetus was in breech presentation.

An external file that holds a picture, illustration, etc.
Object name is 10-1055-s-0035-1547332-i150002-1.jpg

Ultrasound demonstrating massive intracranial mass at 25 weeks' gestation.

Given the high concern for fetal head entrapment during a breech delivery, an external cephalic version (ECV) was attempted but was unsuccessful, likely because of the poor fetal tone and the relatively small fetal torso. Management options that were subsequently considered included another ECV attempt under regional anesthesia, hysterotomy, or dilation and evacuation with cranial destruction. The patient was highly motivated to have a vaginal delivery and wanted to avoid surgery. She was admitted to Labor and Delivery for ECV under epidural anesthesia. Because of the early gestational age, polyhydramnios, and extreme macrocephaly, there was concern that the fetus would return to a breech presentation, even in the setting of a fetal demise. Therefore, an amnioreduction was recommended to assist in maintaining the fetus in a cephalic presentation during induction of labor. A sterile amniocentesis procedure was performed under continuous ultrasound guidance with a 20-gauge needle and approximately 1,200 mL of murky brown fluid was obtained via suction. Following the version, ultrasound demonstrated a posterior defect in the cranium. It remains unclear whether this defect was present before or as a consequence of the version. Alpha-fetoprotein levels in the amniotic fluid were elevated.

The patient was induced with 200 µg misoprostol administered vaginally for two doses 3 hours apart and then started on oxytocin. During delivery, the intracranial mass was propelled through the posterior cranial defect. She ultimately had a vaginal delivery and was discharged home the following morning. The final pathology report described a female fetus ( Fig. 2 ) with a congenital intracranial immature teratoma completely replacing the brain and hydrops fetalis. The tumor weighed 186 g.

An external file that holds a picture, illustration, etc.
Object name is 10-1055-s-0035-1547332-i150002-2.jpg

Macroscopic appearance of the newborn.

Congenital intracranial tumors are very rare and often incidentally diagnosed on routine second or third trimester ultrasound. They are frequently associated with macrocephaly, hydrocephalus, bulging anterior fontanel, or polyhydramnios. 2 Teratomas, as presented in this case, are the most common histologic subtype, accounting for between 36 to 62% of congenital brain tumors; they are most often located supratentorially and are composed of tissue derived from all the following three embryonic germ layers: endoderm, mesoderm, and ectoderm. 3 4 Further classification, as mature or immature, is based on the degree of tissue differentiation. Rapid, invasive tumor growth that destroys and obliterates normal cerebral and cranial structures is responsible for the poor fetal prognosis. The 1-year survival rate is less than 10%. Survivors typically have profound developmental delay. 3 Intrauterine treatment remains an investigational procedure.

ECV following an intrauterine fetal demise is typically unnecessary. With a live fetus undergoing a vaginal breech delivery, there is an increased risk of head entrapment and other fetal injuries. 5 In addition, few providers are sufficiently skilled to perform these deliveries. In this clinical scenario, patients are offered an ECV and, if successful, will proceed with spontaneous or induced labor. With a fetal demise in breech presentation, surgical delivery should be avoided if possible given its inherent risks. This case is unusual given the significant fetal head size and the possibility that a breech delivery could also require a destructive procedure such as cephalocentesis or craniotomy to deliver the head. 6

Decompression amniocentesis has been used in singleton pregnancies complicated by severe and symptomatic polyhydramnios but no randomized trials have evaluated whether it is superior to expectant management. 7 Amnioreduction following ECV is rarely performed. In this case, because of the polyhydramnios and extreme macrocephaly, we felt that this would optimize the stability of the fetal position until delivery was achieved. To our knowledge, this type of management has not been previously reported.

This website is intended for healthcare professionals

{ $refs.search.focus(); })" aria-controls="searchpanel" :aria-expanded="open" class="hidden lg:inline-flex justify-end text-gray-800 hover:text-primary py-2 px-4 lg:px-0 items-center text-base font-medium"> Search

Search menu

Ajibade F, Hirsi-Farah S, Selinger M. Knowledge sharing and basic ultrasound skills for midwives (MWs). Ultrasound in Obstetrics & Gynecology. 2015; 46:162-163 https://doi.org/10.1002/uog.15439

Andrews S. Midwives as obstetric ultrasonographers. Midwives. 2002; 5:(7)216-8

Guidelines for the safe use of diagnostic ultrasound equipment. Ultrasound. 2010; 18:52-59 https://doi.org/10.1258%2Fult.2010.100003

Chiossi G, Palomba S, Balduzzi S, Constantine MM, Falbo AI, La Sala GB. ‘The more the better’ paradox of ultrasound examinations in low-risk pregnancy. Am J Perinatol.. 2016; 33:(7)646-57 https://doi.org/10.1055/s-0035-1571200

Confidential Enquiry into Stillbirths and Deaths in Infancy: 7th Annual Report.London: Maternal and Child Health Research Consortium; 2000

Consortium for the Accreditation of Sonographic Education. Directory of case accredited courses 2017-2018. 2018. http://www.case-uk.org/course-directory (accessed 14 March 2019)

Edvardsson K, Mogren I, Lalos A, Persson M, Small R. A routine tool with far-reaching influence: Australian midwives' views on the use of ultrasound during pregnancy. BMC Pregnancy Childbirth. 2015; 15 https://doi.org/10.1186/s12884-015-0632-y

Edwards H. Midwife sonographer activity in the UK. Evidence-Based Midwifery. 2009; 7:(1)8-15

Hemelaar J, Lim L, Impey L. The impact of an ECV service is limited by antenatal breech detection: a retrospective cohort study. Birth. 2015; 42:(2)165-72 https://doi.org/10.1111/birt.12162

Homer CS, Watts NP, Petrovska K, Sjostedt CM, Bitsis A. Women's experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth. 2015; 15 https://doi.org/10.1186/s12884-015-0521-4

Lydon-Rochelle M, Albers L, Gotwocia J, Craig E, Qualls C. Accuracy of Leopold maneuvers in screening for malpresentation: a prospective study. Birth. 1993; 20:(3)132-5

Nassar N, Roberts CL, Cameron CA, Olive EC. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ. 2006; 333:(7568)578-80 https://doi.org/10.1136/bmj.38919.681563.4F

Norfolk and Norwich University Hospitals NHS Foundation Trust. Safety Scans to Spot Breech Babies. 2016. http://www.nnuh.nhs.uk/news/2016/01/safety-scans-to-spot-breech-babies/ (accessed 14 March 2019)

Management of Breech Presentation: Green-top Guideline No. 20b. BJOG. 2017a; 124:(7)e151-e177 https://doi.org/10.1111/1471-0528.14465

Royal College of Obstetricians and Gynaecologists. Training Matrix: Annual expectation of educational progression ST1 to ST7 in O&G for 2017-18. 2017b. https://www.rcog.org.uk/globalassets/documents/careers-and-training/assessment-and-progression-through-training/training-matrix.pdf (accessed 14 March 2019)

Smith Walker T, Millman N, Taylor M. Integration of a portable ultrasound device into community midwife practice: a feasibility study. ADC Fetal and Neonatal Edition. 2010; 95 https://doi.org/10.1136/adc.2010.189761.47

Su M, McLeod L, Ross S Factors associated with with maternal morbidity in the term breech trial. JOGC. 2007; 29:(4)324-30

Swanson J, Kawooya M, Swanson D, Hippe D, Dungu-Matovu P, Nathan R. 2014. The diagnostic impact of limited, screening obstetric ultrasound when performed by midwives in rural Uganda. J Perinatol.. 2014; 34:(7)508-12 https://doi.org/10.1038/jp.2014.54

Thorp JM, Jenkins T, Watson W. Utility of Leopold maneuvers in screening for malpresentation. Obstet Gynecol.. 1991; 78:(3 Pt 1)394-6

Walker S. Undiagnosed breech: Towards a woman-centred approach. Br J Midwifery. 2013; 21:316-322 https://doi.org/10.12968/bjom.2013.21.5.316

Training in diagnostic ultrasound: essentials, principles and standards. World Health Organ Tech Rep Ser. 1998; 875:i-46

Should midwives learn to scan for presentation? Findings from a large survey of midwives in the UK

Lauren Barnfield

Clinical Research Fellow, Department of Women and Children's Health, Luton and Dunstable Hospital NHS Foundation Trust

View articles

Jacqueline Bamfo

Consultant in Obstetrics and Fetal Medicine, Department of Women and Children's Health, Luton and Dunstable Hospital NHS Foundation Trust

Lynne Norman

Community Midwife, Women's and Children's Department, Milton Keynes University Hospital

Undiagnosed breech presentation in labour is associated with fetal morbidity and mortality, and may cause significant maternal anxiety. With increasing availability of scan machines, ultrasound is now widely used in UK maternity settings. Bedside presentation scans are usually undertaken by junior doctors, often leading to delays and frustration among staff and patients.

To assess local practices and attitudes towards midwives scanning for presentation.

A nine-question anonymous online survey was first disseminated by email locally, and then via social media. It was open to all UK non-sonographer midwives and midwifery students. A total of 870 responses were received between January and April 2018.

The survey highlighted significant variation in practice across the UK. Of those who did not scan for presentation, 85.2% felt that being able to do so would improve their practice, with the majority of respondents highlighting improvements in patient safety and satisfaction as well as workflow.

Conclusions

This demonstrates that demand exists for a postgraduate or accredited short course to teach midwives how to safely and accurately scan to assess fetal presentation.

Fetal lie and presentation in the late third trimester have traditionally been determined by abdominal palpation using Leopold's manoeuvres or a similar technique. Although accuracy may be increased when this is undertaken by an experienced clinician ( Lydon-Rochelle et al, 1993 ), correct diagnosis of non-cephalic presentation may prove difficult, especially in the context of increased maternal BMI or polyhydramnios. Several studies have found palpation alone to have low sensitivity ( Thorp et al, 1991 ; Nassar et al, 2006 ). Unfortunately, in approximately 30% of women whose babies remain breech after 36 weeks' gestation, the diagnosis is made for the first time in labour ( Walker, 2013 ; Hemelaar et al, 2015 ). As ‘high-risk’ women in the UK often receive a late third-trimester ultrasound as part of standard antenatal care, it is a reasonable assumption that many of these women diagnosed in labour with breech presentation would have been ‘low-risk’, and otherwise receiving midwife-led care.

The discovery of an undiagnosed breech in labour is an undesirable outcome, with large population studies reporting it as an independent risk factor for fetal morbidity and mortality ( Confidential Enquiry into Stillbirths and Deaths in Infancy and Maternal and Child Health Research Consortium, 2000 ). Although causation in these cases has not been delineated and many confounding factors exist, advance diagnosis allows for a thorough assessment to identify those women for whom vaginal breech birth may increase the risk of poor neonatal outcome ( Royal College of Obstetricians and Gynaecologists (RCOG), 2017a ). Equally, when detailed antenatal ultrasound assessment demonstrates an absence of such risk factors, it reassures both the woman and the clinicians involved, and informs unbiased, patient-centred decision-making.

Qualitative studies have shown that women find the discovery of breech presentation at term to be extremely stressful, and that it is associated with feelings of loss of choice and control, anger and even grief. Women have described how evidence-based, personalised counselling helped them to make an informed decision and regain a sense of empowerment ( Homer et al, 2015 ). When breech presentation is found unexpectedly in labour, it may add significant pressure to an already fraught situation and balanced counselling to promote an informed choice may be impossible. Many clinicians are not experienced in vaginal breech birth; their feelings of stress and fear may be unconsciously transferred to women, and this situation may result in avoidable emergency operative intervention. The Term Breech Trial secondary analyses reported a three-fold increase in maternal morbidity where caesarean section was undertaken during established labour, compared with vaginal birth ( Su et al, 2007 ).

Ultrasound is now widely used in maternity settings, with all women in the UK offered dating and anomaly scans and many receiving additional scans to monitor fetal growth and wellbeing. Ultrasound is a non-invasive and well-accepted diagnostic tool that, when used appropriately, complements clinical practice and has the potential to prevent fetal and maternal morbidity and mortality. Following established guidelines ( British Medical Ultrasound Society, 2010 ), its safety record when used for diagnostic purposes with standard obstetric settings is well established. In recent years, steadily increasing demand for ultrasound scans has put pressure on departments ( Edwards, 2009 ).

The qualifications and duration of training required to practice obstetric ultrasonography vary greatly worldwide. In some countries all obstetric scanning is undertaken by physicians, and in others the majority of ultrasound scans are undertaken by midwives ( World Health Organization, 1998 ). Routine maternity ultrasound scans in the UK are usually carried out by radiographers, alongside an increasing number of midwife ultrasonographers who have undertaken focused university courses accredited by the Consortium for the Accreditation of Sonographic Education (CASE). These courses (which may be paid for independently or, where demand exists, by hospital Trusts) last between 6 months and 2 years and require a minimum of 120 hours' supervised scanning ( CASE, 2018 ). By contrast, the majority of bedside presentation scans are undertaken by junior doctors training in obstetrics and gynaecology. Teaching for these trainees is usually carried out apprentice-style at the bedside, and there is no specific competence that must be signed off before obstetric doctors may scan independently for presentation, although all trainees must attend a basic ultrasound course (usually 1 or 2 days' duration) within their first 2 years ( RCOG, 2017b ). Scanning for fetal presentation is usually an obstetrician's first experience of ultrasound and, when undertaken prudently with an understanding of machine settings and probe orientation, it is a fast and highly accurate procedure.

The reducing cost of ultrasound technology has led to increased availability of portable scan machines. Worldwide there have been a number of safety initiatives using this new technology. Short ultrasound training courses for midwives and nurses have high sensitivity and specificity for detection of conditions that increase high obstetric risk, including non-cephalic presentation ( Swanson et al, 2014 ).

Over the past few years, a number of UK units have offered in-house training enabling midwives to undertake scans for presentation in labour ward ( Norfolk and Norwich University Hospitals NHS Foundation Trust, 2016 ) and community settings ( Smith Walker et al, 2010 ), with some reporting a significant reduction in rate of undiagnosed breech presentation in labour ( Ajibade et al, 2015 ). There is, however, considerable variation in this practice between hospitals and no guidelines or recommendations for suitable training, which may result in substandard teaching or potentially leave practitioners vulnerable. Although no register of practitioners exists, it is thought that only a small number of UK midwives carry out ultrasound scans, and a survey carried out by the Royal College of Midwives (RCM) in 2008 identified only 197 practitioners from the 58 hospitals who responded. These midwives provided ultrasound for a wide variety of indications: 64% were qualified midwife sonographers and 36% had learned using in-house or other short non-accredited courses ( Edwards, 2009 ).

In 2017, the authors began running a 1-day, hands-on introductory ultrasound course for small groups of midwives. This proved popular, although many of the delegates were not supported by their units to continue scanning afterwards. The possibility of gaining a certificate of accreditation solely for diagnosis of fetal presentation has been explored, but a university who would be willing to support this has not yet been found. This survey of midwives and student midwives was therefore undertaken to learn more about UK-wide variation in practice, midwives' opinions on scanning for presentation and the potential demand for a short course.

A nine-question anonymous online survey was first disseminated by email locally, and then via social media. It was open to all UK non-sonographer midwives (ie midwives who had not completed an accredited postgraduate qualification in sonography) and midwifery students. A total of 870 responses were received over a 3-month period (January to April 2018).

Of the 870 midwives who responded, 38.4% identified themselves as mostly working on the labour ward, with 22.8% in community, 11.6% on wards and 5.5% in a day assessment unit/triage setting. Students made up 7.8% of respondents. All regions of the UK were represented ( Figure 1 ), with south-east England providing the greatest proportion of responses (21.8%) due to a high rate of participation among staff in the local unit.

In response to the question ‘do you currently scan pregnant women for fetal presentation?’, 89.7% of midwives reported that they did not, although several commented that they had in previous roles. A small proportion (7.2%) reported that they scanned women to assess fetal presentation but had never attended a formal course, and 3.0% reported that they had attended a formal course (this includes those who commented that they had undertaken in-house training courses).

When asked in which locations midwives would scan for fetal presentation if able, labour ward (69.3%) and triage/day assessment unit (63.2%) were the most common responses, although many also selected in clinic, on the wards or in the community ( Figure 2 ). Other suggestions included on the midwife-led birthing unit, or before procedures such as induction of labour or caesarean section. Four midwives commented that lack of availability of ultrasound machines would limit this skill in settings such as the community. Four midwives replied that they were completely confident in their abdominal palpation, and would therefore not need to refer patients for scans to confirm. When asked to estimate how often they would scan for fetal presentation if able, 91.8% responded once per month or more frequently, with 40.8% choosing ‘several times per week’ ( Figure 3 ).

Of the 779 midwives and student midwives who did not scan for fetal presentation, 85.2% felt that being able to do so would improve their practice and 93.4% reported that they ‘would like to learn’. When asked ‘would you be interested in attending a structured short course which would result in an accredited certificate of competence in assessing fetal presentation?’, 93.6% responded that they would, which equated to 94.4% of those who did not scan at the time of asking.

Free-text responses

The final question invited further comments and suggestions. Approximately one-quarter of participants responded, with a range of different viewpoints. Some of these comments further highlighted the significant variation in practice across the UK, with several Trusts running in-house training programmes, either for all midwives, or for specific groups (such as midwives working in antenatal clinic, labour ward or day units). The described standards for sign-off also varied, but most often included undertaking observed scans:

‘I had a [5 minute] talk … and [was] observed for 10 scans by a peer.’

‘I have been taught … by our chief antenatal sonographer, it was brief and then I had to be supervised for a few before I could be signed off.’

‘We had to perform 20 under supervision and then were signed off by our fetal medicine consultant.’

Overall, the majority of responses were in support of midwives being taught to scan for fetal presentation. Many of these made reference to the potential improvement in patient safety and experience (and reduction in caesarean section rate) that could be brought about by early diagnosis of breech presentation:

‘Admission [ultrasound] gives the woman a chance to make a choice about possible vaginal birth in a calm way.’

‘Over my many years of practice undiagnosed breeches have resulted in birth trauma, [maybe] … this practice … will help to prevent such things!’

‘With increasing obesity it's even harder to be confident about fetal presentation. It's too late to consider options … when the women present as undiagnosed breech.’

‘It is unacceptable to have an undiagnosed breech in labour when it is so easy to scan for presentation.’

The responses also highlighted how ubiquitous the use of ultrasound was already becoming, with some Trusts requiring presentation scans for all women admitted to the labour ward. One community midwife responded that her Trust used hand-held ultrasound machines to check presentation for all women giving birth outside of a hospital setting. The majority of positive responses made reference to improvement in workflow and patient and staff satisfaction:

‘Obtaining a presentation scan … is the bane of my life. If I could carry out these scans myself it would make things so much easier for the women.’

‘This is an excellent suggestion and a way forward to improve the women's experience in clinic; enhancing senior midwife skills and freeing up medics.’

‘Would save a lot of delayed inductions … which would impact positively on the workload for subsequent shifts.’

‘Would save money in the long term by not wasting so many [scan] slots just for presentation.’

Many community midwives felt similarly:

‘[It] would save the women so much worry about waiting to be squeezed in for a scan in maternity outpatients (which is usually full).’

‘In community it feels like we are always referring women for scans to assess presentation … a lot of these [women] have no mode of transport and it is far.’

Other responses made reference to the use of this skill in maintaining normality:

‘If we can scan and keep a woman normal by confirming a cephalic presentation … this is philosophically enough justification for midwives to utilise [ultrasound].’

‘Women who booked for a [midwife led unit] to have their baby are advised to go to [labour ward] until they have had confirmation—which ultimately can make a difference in their birth choices.’

Similarly, some felt that performing ultrasounds would enhance their professional autonomy:

‘There wouldn't be the need to call doctors … thus reducing stress and anxiety for women and their families.’

‘[This] means the midwife becomes more and more autonomous.’

Several respondents had already investigated the possibility of taking an accredited sonography course, but had given up, either due to either a shortage of available places locally (‘I have been trying to get a place for four years!’ or ‘Have been asking my [hospital] for ages’), or a lack of support and mentorship (‘We [were] granted funding… but the sonographers did not have the capacity or time’). In the RCM survey ( Edwards, 2009 ), midwife sonographers described meeting resistance from other clinicians who felt that scanning was ‘not a midwife's job’. Some of the respondents in this study commented that, given the wide availability of ultrasound machines, it would make sense for presentation scanning to be incorporated into the primary midwifery degree, or as a postgraduate competence, similar to suturing. Interestingly, several responses described having ‘a quick go with the scanner whilst impatiently waiting for the doctor to arrive!’

Unsurprisingly, some respondents were more apprehensive about the idea of midwives scanning for presentation. A general feeling that seemed to underlie some of the less positive comments was that this could contribute to a ‘slippery slope’ and a greater use of technology for technology's sake (‘midwives may use [ultrasound] where they wouldn't have before when they were not trained to’). The most common concern ( n =30; 3.4%), was that use of ultrasound to check presentation could undermine clinical skills:

‘Reliance on technology takes away from a midwife's palpation skills … which tells us so much more than just position.’

‘My concern would be … deskilling midwives and losing another part of the art of midwifery.’

‘Staff will lose the skill of abdominal palpation … this is similar to the management of vaginal breech delivery where we no longer have staff with the skills to support women who wish to achieve this.’

However, one respondent felt that the use of ultrasound could improve clinical skills:

‘Linking presentation [findings] noted on scan with corresponding manual palpation [could] ensure that [skills are] retained and developed.’

Another frequently mentioned concern was that the use of ultrasound could contribute to increased medicalisation of the birthing experience:

‘This could potentially … over medicalise our role and women's' birthing experiences which are medicalised enough.’

‘I believe … we are medicalising normality by intending to do this in every woman.’

These views contradicted those of the midwives who felt that the use of ultrasound in low-risk settings could avoid unnecessary obstetric referrals; however, they are consistent with those expressed by midwives in a qualitative study about ultrasound undertaken in Australia ( Edvarsson et al, 2015 ). One study undertaken in the US found that having more than four ultrasound scans was an independent risk factor for caesarean section in low-risk women ( Chiossi et al, 2016 ). However, this argument is less valid when referring solely to scanning for presentation after the finding of uncertain presentation on palpation, as an ultrasound scan would be required regardless of practitioner.

Many midwives commented that ultrasound should be used only where clinical examination findings were unclear (‘should not be completed on all women as an ‘easy’ option’) and only after 36 weeks' gestation; indeed, there is generally no merit in assessing presentation before this except in cases of preterm labour or rupture of membranes. Four respondents were concerned about the effect of ultrasound on the fetus (‘I am yet to see evidence that proves that ultrasound does not cause fetal harm’). Finally, three respondents felt concerned that this would increase workload and responsibility for midwives, especially with no commensurate increase in salary:

‘We don't need any other strings to our bow … we may as well be paid as doctors … at present we are not … our role is continually expanding and we are supposed to just suck it up. It's not that this wouldn't be useful … but when we get it wrong and we have been trained in the use of [ultrasound] the midwife will be blamed yet again.’

‘Midwives have a lot of responsibility as it is … what if you scanned the woman and potentially missed something that was wrong?’

Several comments were made about the proposal of a short (1- or 2-day) course to learn how to scan for fetal presentation, with the majority of midwives viewing it as a positive step (‘there is definitely a gap in the market … a short course would be much more appealing’). In keeping with the findings above, where 85.2% felt that learning to scan would improve [their] practice and 93.4% ‘would like to learn’, some of the respondents indicated that they would find attending such a course interesting, with one midwife describing how she ‘really enjoy[s] doing… scans’. Suggestions included setting a national qualification or standard recognised by all Trusts, to ensure that teaching was consistent and adequate. Two midwives raised concerns about the potential financial cost of such a course.

This large survey of UK midwives and students demonstrated significant variation in practice across the country, with 10.3% of respondents carrying out presentation scans in their practice. Maternity care in the UK is evolving, and the use of ultrasound is becoming more widespread. Many hospitals now require routine presentation scans before all inductions, increasing the workload for busy obstetric staff and potentially leading to delays. Ultrasound assessment of fetal presentation is a low-complexity skill that can be safely taught in a short period of time and, with the increasing availability and reducing cost of portable ultrasound, this can be done in a variety of settings. Where used as an adjunct to traditional midwifery skills and techniques, it may improve patient safety and satisfaction as well as workflow. As Andrews (2002) states:

‘This is not a zero-sum gain, where midwives need to make a choice between traditional midwifery skills and modern techniques. It is about successfully using the best opportunities available for midwifery care—old and new.’

The role of the midwife has expanded and evolved significantly over recent years to meet the changing demands of the population. Practical skills such as suturing and cannulation have become standard practice, and various specialist midwife roles have been introduced. In line with this, fetal presentation scanning could be incorporated into the scope of practice of a select group of midwives. The majority of respondents were interested, and so the main factor prohibiting development of this skill could be a lack of a consistent and clear guideline or competency assessment. Although there are midwife sonography courses available, these are expensive, time-consuming and require significant local support and supervision. Training for those who only wish to carry out presentation scans is (where available) usually done in-house, where the standard and content of teaching will vary, and any agreed competence may not be transferable between Trusts. Introduction of clear national guidelines for midwives wishing to learn to scan for presentation, or the development of a short course that would result in a nationally accredited certificate of competence would appear to be a sensible next step.

Undiagnosed breech presentation in labour increases fetal morbidity and mortality as well as maternal anxiety and may deny women the opportunity to make a calm, evidence-based decision about mode of birth
Ultrasound is used safely as part of routine UK antenatal care. This is usually undertaken by radiologists or trained midwife sonographers; however, bedside fetal presentation scans are often carried out by junior obstetric doctors with no formal training
Some units in the UK run in-house short courses for midwives who wish to learn to scan for fetal presentation, but the teaching is not consistent and may not be transferable between Trusts
This survey of 870 UK midwives and student midwives found that a majority felt that this skill would improve their practice, with respondents highlighting potential improvements in workflow and patient safety and satisfaction
Concerns were expressed that widespread use of ultrasound by midwives could result in loss of clinical skills and increase the workload and responsibility of already overstretched staff
There is demand for the introduction of a postgraduate competence or university-accredited short course to teach interested midwives how to safely and accurately undertake fetal presentation scans

CPD reflective questions

How often do you feel unsure when assessing fetal presentation by palpation, for example in women with raised BMI?
What positives and negatives might be associated with the increasing use of ultrasound in maternity settings?
How do you think midwives scanning for presentation would affect patient satisfaction and workflow in your area?
How can high-quality, standardised training in presentation scanning best be delivered to midwives in the UK?

IMAGES

Cephalic Presentation of Baby During Pregnancy
Polyhydramnios
Polyhydramnios Information
cephalic presentation
Polyhydramnios
four types of cephalic presentation #craniosacraltherapy #craniosacral

VIDEO

Fetal Attitude. Cephalic Presentation. Obstetrics
Itiology of Polyhydramnios.Part 2
Cephalic presentation in pregnancy #baby #preganacy #gynaecologists #apollohospitals
Polyhydramnios.#pregnancy#obstetricsandgynecology
CEPHALIC PRESENTATION #midwifesally #preganacy #duringpregnancy
Itiology of polyhydramnios.Part 3

COMMENTS

Polyhydramnios
Polyhydramnios is a pathologic excess of amniotic fluid volume (AFV) in pregnancy.[1] It represents a high-risk obstetric condition with increased perinatal and maternal morbidity and mortality due to a higher incidence of intrauterine fetal demise, preterm labor, premature rupture of membranes, cord prolapse, fetal macrosomia, breech presentation, cesarean delivery, and postpartum hemorrhage ...
Polyhydramnios: Causes, Symptoms, Complications & Treatment
Shortness of breath. Heartburn. Difficulty pooping ( constipation ). Peeing more often. Swelling in your vulva (external genitals), legs and feet. When your uterus gets larger, it puts pressure on nearby organs like your lungs, stomach, rectum and bladder. This added pressure is typically the cause of your symptoms.
Polyhydramnios
Polyhydramnios (pol-e-hi-DRAM-nee-os) is the buildup of increased amniotic fluid — the fluid that surrounds the baby in the uterus during pregnancy. Polyhydramnios happens in about 1% to 2% of pregnancies. Most of the time, the condition is mild. It's often found during the middle or later stages of pregnancy.
Fetal Presentation, Position, and Lie (Including Breech Presentation
Head first (called vertex or cephalic presentation) Facing backward (occiput anterior position) Spine parallel to mother's spine (longitudinal lie) Neck bent forward with chin tucked. Arms folded across the chest . If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not ...
Abnormal Fetal lie, Malpresentation and Malposition
Abnormal Fetal Lie. If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation. ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen. It has an approximate success rate of 50% in primiparous women and 60% in multiparous women.
Compound Presentations
The most common causal factor is prematurity. Others include high presenting part with ruptured membranes, polyhydramnios, multiparity, a contracted pelvis, pelvic masses, and twins. It is also more common with inductions of labor involving floating presenting parts. Another predisposing factor is external cephalic version.
Delivery, Face and Brow Presentation
The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin.
Leopold Maneuvers
In the cephalic presentation, the hand is placed flat on the pubic symphysis, and the palpation could delineate the fetal head portion that can be reached above the pelvic inlet. ... Leopold maneuvers have been reported to be difficult in obese pregnant women and pregnancies complicated with polyhydramnios, fibroids, or anterior placental ...
Chapter 15: Abnormal Cephalic Presentations
The fetus enters the pelvis in a cephalic presentation approximately 95 percent to 96 percent of the time. In these cephalic presentations, the occiput may be in the persistent transverse or posterior positions. ... Polyhydramnios: An excessive amount of amniotic fluid allows the baby freedom of activity, and he or she may assume abnormal ...
Chapter 63: External Cephalic Version
Breech presentation occurs in 3% to 4% of labors. 1 It is more common earlier in gestation, with 25% of pregnancies <28 weeks and 7% of pregnancies at 32 weeks being complicated by breech presentation. 1 There are three types of breech presentation: frank, complete, and incomplete (also known as footling) ().Factors associated with breech presentation include such fetal malformations as ...
KEMH Clinical Practice Guideline- Abnormalities of Lie/Presentation
First stage management Care is the same as in cephalic presentation, with some additional care for the management of an uncomplicated term breech presentation. ... Fetal causes of unstable lie include polyhydramnios,28 oligohydramnios, multiple pregnancy28, fetal macrosomia, and fetal abnormalities (e.g. hydrocephaly, abdominal distension ...
Breech Presentation
Fetal presentation should be assessed and documented beginning at 36 0/7 weeks of gestation to allow for external cephalic version to be offered. Risk factors for breech presentation include prematurity, uterine anomaly, polyhydramnios, prior term breech presentation, multiple pregnancy, placenta previa, and fetal anomalies.
Predictors of a successful external cephalic version: A population
Breech presentation affects approximately 3% of women with singleton pregnancies and is a contributing factor to high rates of caesarean birth. External cephalic version can reorient the foetus, but predictors of the procedure's success have not been studied in a contemporary population-based sample in the United States. What is already known
Cephalic presentation
A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation, where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations ...
Ultrasound in Obstetrics & Gynecology
Cephalic presentation: 43 416 (94.7) 10 277 (23.7) Remained cephalic at birth: 43 307 (99.7) 10 168 (23.5) Spontaneous rotation to breech/transverse: 109 (0.3) ... oligohydramnios or polyhydramnios and in nulliparous than parous women, and was lower in women of South Asian or mixed racial origin than in white women. Third, about 20% of cases of ...
Breech Presentation
Polyhydramnios: Fetus is often in unstable lie, unable to engage. Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid ... L. Predictors of success of external cephalic version and cephalic presentation at birth among 1253 women with non-cephalic presentation using logistic regression and classification tree analyses. Acta ...
Contraindications for external cephalic version in breech position at
External cephalic version (ECV) at or near term is a safe procedure that effectively reduces the risk of a CS in pregnancies with breech presentation . International guidelines recommend that all women with an uncomplicated breech pregnancy at term should be offered an ECV . These guidelines also mention contraindications for ECV, restricting ...
External Cephalic Version and Reducing the Incidence of Term Breech
Summary: This guideline presents the best evidence concerning methods to prevent noncephalic presentation at delivery and therefore caesarean section and its sequalae.The mode and technique of delivering a breech presentation is summarised in the Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 20b Management of Breech Presentation.
Fetal presentation: Breech, posterior, transverse lie, and more
Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. ... This is called an external cephalic version, and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth ...
Use of External Cephalic Version and Amnioreduction in the Delivery of
Because of the early gestational age, polyhydramnios, and extreme macrocephaly, there was concern that the fetus would return to a breech presentation, even in the setting of a fetal demise. Therefore, an amnioreduction was recommended to assist in maintaining the fetus in a cephalic presentation during induction of labor.
Obstetric emergencies: umbilical cord prolapse
Umbilical cord prolapse (UCP) is a rare and sudden obstetric emergency. The incomplete engagement of the fetal presenting part with the cervix and lower uterine segment leads to a gap into which the umbilical cord can descend and then become entrapped. Guidelines from the Royal College of Obstetricians (RCOG) describes three types of UCP, namely overt, occult and cord presentation.1 Overt UCP ...
Should midwives learn to scan for presentation? Findings from a large
Fetal lie and presentation in the late third trimester have traditionally been determined by abdominal palpation using Leopold's manoeuvres or a similar technique Although accuracy may be increased when this is undertaken by an experienced clinician (Lydon-Rochelle et al, 1993), correct diagnosis of non-cephalic presentation may prove difficult, especially in the context of increased maternal ...