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Fetal Malpresentation

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21. Breech presentation

Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned caesarean section. History and exam presence of risk factors buttocks or feet as the presenting part fetal head under costal margin fetal heartbeat above the maternal umbilicus subcostal tenderness pelvic or bladder pain premature fetus small for gestational age fetus nulliparity fetal congenital anomalies previous breech delivery uterine (...) of preterm birth, small fetal size, congenital anomalies, and perinatal mortality. Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies. Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned caesarean section, the optimal gestation being 37 and 39 weeks, respectively. Planned caesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term

2018 BMJ Best Practice

22. Placenta Praevia and Placenta Accreta: Diagnosis and Management (Full text)

urgently. Grade of recommendation: ✓ Maternal complications at caesarean section increase when the primary surgeon is a trainee rather than an experienced surgeon. Placenta praevia is often associated with additional complications, including fetal malpresentation (transverse or breech presentation) requiring complex intraoperative manoeuvres to deliver the baby. Evidence level 4 6.2 What anaesthetic procedure is most appropriate for women having a caesarean section for placenta praevia? Regional (...) praevia or a low‐lying placenta, if so, at what gestation and with what follow‐up? The midpregnancy routine fetal anomaly scan should include placental localisation thereby identifying women at risk of persisting placenta praevia or a low‐lying placenta. [ New 2018 ] Grade of recommendation: ✓ The term placenta praevia should be used when the placenta lies directly over the internal os. For pregnancies at more than 16 weeks of gestation the term low‐lying placenta should be used when the placental

2018 Royal College of Obstetricians and Gynaecologists PubMed abstract

23. Care around stillbirth and neonatal death

regional differences exist. In New Zealand, perinatal death consists of fetal death (the death of a fetus of from 20 weeks gestation or weighing at least 400 grams if gestation is unknown 7 ) and early neonatal death (the death of a liveborn baby that occurs before the 7 th day of life 5 ). Perinatal related mortality is fetal and neonatal deaths (up to 28 days) at 20 weeks or beyond, or weighing at least 400g if gestation is unknown. Fetal death includes stillbirth and termination of pregnancy 8 (...) , giving a PMR of 11.2 per 1000 (8.1 and 3.1/1000 for fetal and neonatal death rates respectively) 5 . For Indigenous and other disadvantaged women in both settings (similar to other high income settings), the risk of perinatal death is around double 5,6,9,17 . Using the PSANZ classification system the leading causes of stillbirth are congenital anomaly and spontaneous preterm. However in approximately 20-30% of stillbirths, a cause is never identified. Similarly, for neonatal mortality, the main cause

2019 Centre of Research Excellence in Stillbirth

24. Primary postpartum haemorrhage

the need for episiotomy o Refer to Queensland Clinical Guideline: Perineal care 38 Emergency CS · Ensure IV access · Send urgent blood for: o FBC o Group and hold (if no valid group and hold available) o Cross match in selected circumstances if indicated · Experienced obstetrician required if: o Increased risk of extensions or lacerations (e.g. deep engagement of the fetal head, failed assisted vaginal birth) o Malpresentation o Evidence of abnormal coagulation o History of previous PPH or other (...) haemorrhage 3.5.3 Uterine rupture Uterine rupture can occur spontaneously or be associated with previous obstetric surgery. The severity of the haemorrhage depends upon the extent of the rupture. Table 25. Uterine rupture Aspect Considerations Risk factors 68,69 · Previous uterine surgery or CS · Oxytocin administration · Malpresentation or undiagnosed cephalopelvic disproportion · Dystocia during second stage of labour · Grand multiparity · Macrosomic fetus · Placenta percreta · Uterine abnormalities

2019 Queensland Health

25. Female Infertility

uterus have a unilateral renal anomaly [79]. A meta-analysis of 9 studies investigating reproductive outcomes in women with congenital uterine anomalies grouped women into 3 different categories: arcuate uteri, canalization defections, and unification defects. Those with arcuate uteri were found to have an increased rate of second-trimester pregnancy loss and fetal malpresentation. Those with canalization defects such as septate and subseptate uteri were found to have difficulty conceiving, first (...) -trimester pregnancy loss, preterm birth, and fetal malpresentation. Those with unification defects such as unicornuate, bicornuate, and didelphys uteri suffered increased incidence of preterm birth and fetal malpresentation [80]. In 24 cases of surgically proven MDA, MRI was 100% accurate, 2-D TVS was 92% accurate, and hysterosalpingogram was only 16.7% accurate [26]. Although HSG can visualize the uterine cavity, it cannot provide information about the external uterine contour, preventing accurate

2019 American College of Radiology

26. Obstetric Management at Borderline Viability

, magnesium sulfate should be administered in the extreme preterm population in accordance with local protocols and the existing SOGC guideline (Strong, Moderate). 7. Other than for maternal indications, routine Caesarean delivery in the extreme preterm population should be avoided (Strong, High). In cases of fetal malpresentation or other obstetric indications, the limitations of evidence should be discussed and a multidisciplinary approach should be used to come to a decision that considers both (...) statements to guide clinical practice and recommendations for obstetric management of a pregnancy at borderline viability, currently defined as prior to 25+6 weeks. Intended Users Clinicians involved in the obstetric management of women whose fetus is at the borderline of viability. Target Population Women presenting for possible birth at borderline viability. Evidence This document presents a summary of the literature and a general consensus on the management of pregnancies at borderline viability

2017 Society of Obstetricians and Gynaecologists of Canada

27. Management of Pregnancy

complications and morbidity • Emphasize the use of patient-centered care (PCC) II. Background A. Description of Pregnancy Pregnancy is the reproductive time during which a developing fetus grows inside of the uterus. It is a time of dramatic change for a developing fetus and a woman’s body. Most pregnancies are uncomplicated and labor results in a normal vaginal birth with a healthy mother and baby. Rarely, complications arise, which have the potential to lead to lifelong implications. As the fetus (...) may be planned for breech presentation, prior uterine surgery, or as a response to unexpected maternal or fetal complications such as abnormal labor or a concerning fetal heart rate.[ ] Cesarean delivery is a major surgery with associated risks (e.g., risk of infection, hemorrhage). Cesarean delivery requires a longer period for maternal recovery than vaginal birth and has also been associated with neonatal complications, primarily respiratory.[ ] There has been a downward trend in cesarean births

2018 VA/DoD Clinical Practice Guidelines

28. CRACKCast E180 – Labor & Delivery

weeks’ gestation, any medical assessment should include the mother and fetus because fetal viability becomes established near that time. False labour (Braxton Hicks contractions) True labour ● Small, uncoordinated uterine contractions ● No escalation of frequency or duration ● No cervical dilation or effacement ● Intact membranes ● Relieved with analgesia, ambulation and change in activity ● Cyclic coordinated contractions ● Escalation of frequency, duration and severity ● Ruptured membranes (...) becomes firmer and rises; the umbilical cord lengthens 5 to 10 cm; or there is a sudden gush of blood. Laceration repair Oxytocin infusion Uterine checks ending with a completely dilated, fully effaced cervix. Ends with the delivery of the baby Ends with placental delivery First hour post delivery Watch for PPH! 3) List 3 techniques for monitoring the fetus. Clinical monitoring External electronic fetal monitoring Ultrasonography Let’s go through them in more detail: Clinical monitoring No real time

2018 CandiEM

29. Induction of labour

not leave catheter in situ longer than 18 hours) · Reassess in birth suite · Recommend ARM No Continue IOL Recommend immediate commencement of oxytocin ARM successful? Obstetric review Consider: · Dinoprostone, or · Reinsert catheter after 24 hours Yes No Post procedure observation and care · Pulse, BP, FHR, uterine activity, engagement of fetal head and vaginal loss o Immediately, and repeat at 30 minutes o Medical review if malpresentation or fetal head 5/5 palpable after insertion o CTG not required (...) or uterine surgery · Malpresentation/high presenting part · Undiagnosed PV bleeding · Abnormal CTG/fetal compromise Cautions · Multiple pregnancy · Asthma, chronic obstructive pulmonary disease: may cause bronchospasm · Epilepsy · Cardiovascular disease · Raised intraocular pressure, glaucoma · Avoid concurrent oxytocin use ARM: Artificial rupture of membranes; BP: Blood pressure; CS: Caesarean section; CTG: Cardiotocography; FHR: Fetal heart rate; IOL: Induction of labour; MBS: Modified Bishop Score; PV

2018 Queensland Health

30. Insertion of a double balloon catheter for induction of labour in pregnant women without previous caesarean section

) of 126 women with oligohydramnios and unfavourable cervices. 5.2 'Fetal malpresentation after catheter removal' was reported in 2 women in the DBC group (1 had a fetus with face presentation and 1 had a fetus with a transverse lie) in an RCT of 302 pregnant women (293 in the final analysis) comparing DBC (n=148) against single balloon catheter (SBC; n=145). One woman had a vaginal delivery after an external cephalic version was performed and 1 had a caesarean section. Insertion of a double balloon (...) saline is infused at the same time. The mother and fetus are monitored and the device is left in place for up to about 12 hours. If labour begins, or spontaneous device expulsion or rupture of membranes have occurred, or if fetal distress is suspected, the balloons are deflated and the device is removed to facilitate labour management. If labour does not begin spontaneously, the membranes are ruptured artificially and oxytocin infusion is started. 4 4 Efficacy Efficacy This section describes efficacy

2015 National Institute for Health and Clinical Excellence - Interventional Procedures

31. Flowchart: Induction of labour, Artificial rupture of membranes (PDF, 106kB)

(MBS = 7) • Before oxytocin infusion commenced Relative contraindications • Poor application of the presenting part/unstable lie • Fetal head not engaged Induction of labour See flowchart: Method of induction Artificial rupture of membranes (ARM) ARM • Continue to ARM from assessment VE • Confirm passage of fluid and check for presence of blood and meconium • Ensure good application of presenting part before completing VE • FHR immediately following procedure Consult obstetrician Pre ARM • Complete (...) pre IOL assessment • Encourage to empty bladder • Abdominal palpation to determine: o Descent o Position o Presentation VE to identify: • Stage of labour • MBS • Presentation • Position and descent • Membranes Assess for clinical concerns: • Polyhydramnios • Head not engaged • Malpresentation • Possible cord presentation • Unstable lie FHR or liquor abnormalities? CTG Discuss, refer or consult as indicated Post ARM care • Immediately after procedure document: o Abdominal palpation o VE findings o

2017 Queensland Health

32. Flowchart: Induction of labour, Prostaglandin E2 (Dinoprostone) (PDF, 118kB)

, ongoing care as for latent first stage of labour · Continuous CTG when in active labour or when contractions are = 3 in 10 minutes · After insertion advise woman to: o Remain recumbent for 30 minutes o Inform staff as soon as contractions commence Yes No Yes No Recommend ARM irrespective of MBS PESSARY removal indications · Onset of regular, painful uterine contractions, occurring every 3 minutes regardless of cervical change · Ruptured membranes · Fetal distress · Uterine hyperstimulation (...) or hypertonic uterine contractions · Maternal systemic adverse effects (e.g. nausea, vomiting, hypotension, tachycardia) · Insufficient cervical ripening after 24 hours Indications · Unfavourable cervix (MBS = 6) · Following balloon catheter if no/ minimal effect on cervical ripening and ARM not technically possible Contraindications · Known hypersensitivity · Ruptured membranes · Multiparity = 5 · Previous CS or uterine surgery · Malpresentation/high presenting part · Undiagnosed PV bleeding · Abnormal CTG

2017 Queensland Health

33. Flowchart: Induction of labour, Balloon catheter (PDF, 117kB)

in birth suite • Recommend ARM No Continue IOL Recommend immediate commencement of oxytocin ARM successful? Obstetric review Consider: • Dinoprostone, or • Reinsert catheter after 24 hours Yes No Post procedure observation and care • Pulse, BP, FHR, uterine activity, engagement of fetal head and vaginal loss o Immediately, and repeat at 30 minutes o Medical review if malpresentation or fetal head 5/5 palpable after insertion o CTG not required (unless other indications) • If observations normal (...) ripening and ARM not technically possible • Reduced risk of uterine hyperstimulation is desirable Contraindications • Ruptured membranes • Undiagnosed bleeding • Simultaneous use of prostaglandins • Low lying placenta • Polyhydramnios • Abnormal FHR auscultation or CTG Relative contraindications • Antepartum bleeding • Lower tract genital infection • Fetal head not engaged (4/5 or 5/5 above pelvic brim Insertion procedure • Pre catheter insertion: o Ensure pre IOL assessment complete o Encourage

2017 Queensland Health

34. Guideline supplement: Induction of labour

if malpresentation or fetal head 5/5 palpable after insertion” Amendment to Flowchart Balloon catheter as above July 2018 MN17.22-V7-R22 Change to TGA approvals for cervidil (dinoprostone) Table 19: Indications for removal of dinoprostone pessary amended From: Insufficient cervical ripening after 12 hours To: Insufficient cervical ripening after 24 hours Table 16: Balloon (transcervical) catheter insertion amended at ‘Equipment’ From: 26 French gauge Foley catheter To: Foley catheter with balloon capacity (...) Clinical Guideline Supplement: Induction of labour Refer to online version, destroy printed copies after use Page 4 of 16 Publication date Identifier Summary of major change March 2017 MN17.22-V5-R22 First complete guideline review Endorsed by: · QCG Steering Committee · Statewide Maternity and Neonatal Clinical Network June 2017 MN17.22-V6-R22 Amendment to Table 17 Post balloon catheter insertion. Added to first row of table-monitoring: “engagement of the fetal head” and “medical review required

2017 Queensland Health

35. Periviable Birth

for administration of antenatal steroids, antibiotics to prolong latency after preterm premature rupture of membranes or for intrapartum group B streptococci prophylaxis, and delivery, including cesarean delivery, for concern regarding fetal well-being or fetal malpresentation. Whenever possible, periviable births for which maternal or neonatal intervention is planned should occur in centers that offer expertise in maternal and neonatal care and the needed infrastructure, including intensive care units (...) is predicted to improve this outcome. Although maternal risks associated with individual interventions may not vary widely with a neonate’s gestational age, expectations for anticipated benefit to neonatal outcome may more strongly support undertaking such risks at later gestational ages. Because preterm birth frequently is associated with fetal malpresentation, whether to undertake a cesarean delivery for malpresentation is a relatively common question related to periviable gestation. Earlier cesarean

2017 American College of Obstetricians and Gynecologists

36. Planned Home Birth

; the availability of a certified nurse–midwife, certified midwife or midwife whose education and licensure meet International Confederation of Midwives’ Global Standards for Midwifery Education, or physician practicing obstetrics within an integrated and regulated health system; ready access to consultation; and access to safe and timely transport to nearby hospitals. The Committee on Obstetric Practice considers fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute (...) fetal malpresentation, multiple gestation, or prior cesarean delivery to be an absolute contraindication to planned home birth. In the United States, approximately 35,000 births (0.9%) per year occur in the home ( ). Approximately one fourth of these births are unplanned or unattended ( ). Among women who originally intend to give birth in a hospital or those who make no provisions for professional care during childbirth, home births are associated with high rates of perinatal and neonatal mortality

2017 American College of Obstetricians and Gynecologists

37. Intrapartum care for healthy women and babies

tr ansferred (% of total transferred from each ansferred from each setting) setting) F From home rom home (n=3,529) (n=3,529) F From a freestanding rom a freestanding midwifery unit (n=2,457) midwifery unit (n=2,457) F From an alongside rom an alongside midwifery unit midwifery unit (n=4,401) (n=4,401) Delay during first or second stage of labour 1,144 (32.4%) 912 (37.1%) 1,548 (35.2%) Abnormal fetal heart rate 246 (7.0%) 259 (10.5%) 477 (10.8%) Request for regional analgesia 180 (5.1%) 163 (6.6 (...) Preterm labour or preterm prelabour rupture of membranes Placental abruption Anaemia – haemoglobin less than 85 g/litre at onset of labour Confirmed intrauterine death Induction of labour Substance misuse Alcohol dependency requiring assessment or treatment Onset of gestational diabetes Malpresentation – breech or transverse lie BMI at booking of greater than 35 kg/m 2 Recurrent antepartum haemorrhage Small for gestational age in this pregnancy (less than fifth centile or reduced growth velocity

2014 National Institute for Health and Clinical Excellence - Clinical Guidelines

38. Induction of labour: misoprostol vaginal delivery system

-inferiority to dinoprostone was not met. Uterine tachysystole with fetal heart rate changes or tachysystole requiring intervention was 3 times higher with misoprostol compared with dinoprostone (13.3% compared with 4.0%, p<0.001). The summary of product characteristics states that the most common adverse events are abnormal uterine contractions, fetal heart rate disorder, abnormal labour affecting the fetus and meconium in the amniotic fluid. P Patient factors atient factors Prolonged labour is associated (...) common in the dinoprostone group (all p<0.05). There was no significant difference between the groups in the rate of admission to neonatal intensive care. The EXPEDITE study was well designed and well reported, and allocation was concealed. However, the inclusion and exclusion criteria limit the generalisability of the results. For example, women aged under 18 years, women with multiple pregnancies or more than 3 previous vaginal deliveries, and women with fetal malpresentation were not included

2014 National Institute for Health and Clinical Excellence - Advice

39. Birth after Previous Caesarean Birth

than 4 kg (or similar/lower birthweight than index caesarean delivery 106 ) are associated with an increased likelihood of successful VBAC. 90,93,107–110 In addition, spontaneous onset of labour, vertex presentation, fetal head engagement or a lower station, and higher admission Bishop score also increase the likelihood of successful VBAC. 91,94,103,108,111 Successful VBAC is more likely among women with previous caesarean for fetal malpresentation (84%) compared with women with previous caesarean (...) in a planned VBAC, although an increasing requirement for pain relief in labour should raise awareness of the possibility of an impending uterine rupture. Women should be advised to have continuous electronic fetal monitoring for the duration of planned VBAC, commencing at the onset of regular uterine contractions. How should women with a previous caesarean birth be advised in relation to induction or augmentation of labour? P C B B P P C B C B C C D DRCOG Green-top Guideline No. 45 © Royal College

2015 Royal College of Obstetricians and Gynaecologists

40. Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis. (Full text)

), failed induction (0.56;0.37-0.85), and fetal malpresentation (1.66;1.38-2.01)). Adjusted ORs were similar.Diabetes, HDCP, Bishop score, labor induction, macrosomia, age, obesity, previous vaginal birth, and the indications for the previous CS should be considered as the factors affecting the success of VBAC. (...) Factors associated with successful vaginal birth after a cesarean section: a systematic review and meta-analysis. Evidence for the relationship between maternal and perinatal factors and the success of vaginal birth after cesarean section (VBAC) is conflicting. We aimed to systematically analyze published data on maternal and fetal factors for successful VBAC.A comprehensive search of Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature, from each database's

2020 BMC pregnancy and childbirth PubMed abstract

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