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Fetal Malpresentation

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21. 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 (...) , including maternal transfer and consultation, administration of antenatal corticosteroids and magnesium sulfate, fetal heart rate monitoring, and considerations in mode of delivery. Medline, EMBASE, and Cochrane databases were searched using the following keywords: extreme prematurity, borderline viability, preterm, pregnancy, antenatal corticosteroids, mode of delivery. The results were then studied, and relevant articles were reviewed. The references of the reviewed studies were also searched, as were

2017 Society of Obstetricians and Gynaecologists of Canada

22. Management of Pregnancy

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 (...) to make informed decisions. Clinicians must be adept at presenting information to their patients regarding individual treatments, expected outcomes, and levels and/or locations of care. During pregnancy, this includes presenting the mother, and her support system as appropriate, information about maternal and fetal risks of untreated symptoms and maternal and fetal benefits and risks of proposed care. Clinicians are encouraged to use SDM to individualize treatment goals and plans based on patient

2018 VA/DoD Clinical Practice Guidelines

23. CRACKCast E180 – Labor & Delivery

biophysical profile Fetal tachycardia Decreased variability of fetal heart rate Management: Ampicillin PLUS gentamicin Cefoxitin Pip-tazo Ertapenem If post partum: Ampicillin PLUS gentamicin PLUS (Clindamycin or metronidazole) 10) List four types of malpresentation. What are most common problems of malpresentation? Complicated deliveries, involving dystocia, malpresentation, and multiple gestations, are potentially life-threatening emergencies. The emergency clinician cannot solve these obstetric problems (...) of cord prolapse are unexpected and develop during the second stage of labor. Risk factors: We’ll just list the Fetal and Maternal causes (from Uptodate) Malpresentation (breech, transverse, oblique, or unstable lie) Prematurity Low birth weight Second twin Low lying placentation Pelvic deformities Uterine malformations/tumors External fetal anomalies Multiparity Polyhydramnios Long umbilical cord Unengaged presenting part Prolonged labor Cord prolapse has a variable rate of association with different

2018 CandiEM

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Comparing variation in hospital rates of cesarean delivery among low risk women using 3 different measures

/placental factors x 665.14 RUPTURE UTERUS DURING/AFTER Uterine/placental factors x 669.6 BREECH EXTRACTION WITHOUT ME Malpresentation x 669.60 BREECH EXTR NOS-UNSPEC Malpresentation x x 669.61 BREECH EXTR NOS-DELIVER Malpresentation x x x 678.10 FETAL CONJOIN TWINS-UNSP Fetal factors x x 678.11 FETAL CONJOIN TWINS-DEL Fetal factors x x 678.13 FETAL CONJOIN TWINS-ANTE Fetal factors x x 761.5 MULT PREGNANCY AFF NB Multiple gestation x x x V08 ASYMP HIV INFECTN STATUS Maternal factors x V27.1 DELIVER (...) Comparing variation in hospital rates of cesarean delivery among low risk women using 3 different measures Society for Maternal-Fetal Medicine (SMFM) Special Report: Comparing variation in hospital rates of cesarean delivery among low-risk women using 3 different measures Joanne C. Armstrong, MD, MPH; Katy B. Kozhimannil, PhD, MPA; Patricia McDermott, RN; George R. Saade, MD; Sindhu K. Srinivas, MD, MSCE; for the Society for Maternal-Fetal Medicine Health Policy Committee Measurement of the low

2016 Society for Maternal-Fetal Medicine

33. 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

34. Core Competencies for Management of Labour

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Annex 1: Suggested Education Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Decision Support Tools 1 . Obstetrical T riage and Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2. Intrapartum Fetal Health Surveillance (...) KNOWLEDGE of: SKILL in: JUDGMENT or reasoning in: ATTITUDE by: 1. Assessment • Maternal anatomical and physiological adaptation to pregnancy, labour and birth 1 • Psychosocial adaptations of pregnancy and in labour and birth • Fetal growth and development pattern during pregnancy, including placental function and fetal heart rate adaptation • Comprehensive assessment of fetal well being including gestational age and fetal growth assessment • Comprehensive maternal assessment including demographic

2014 British Columbia Perinatal Health Program

35. Adverse obstetric outcomes among female childhood and adolescent cancer survivors in Sweden: A population-based matched cohort study. (PubMed)

for cancer and the outcome variables, adjusting for maternal age, nicotine use and comorbidity.Survivors were more likely to have preeclampsia (adjusted odds ratio [aOR] 3.46, 95% confidence interval [CI] 1.58 to 7.56), undergo induction of labor (aOR 1.66, 95% CI 1.05 to 2.62), suffer labor dystocia (primary labor dystocia aOR 3.54, 95% CI 1.51 to 8.34 and secondary labor dystocia aOR 2.43, 95% CI 1.37 to 4.31), malpresentation of fetus (aOR 2.02, 95% CI 1.12 to 3.65) and imminent fetal asphyxia (aOR

2019 Acta Obstetricia et Gynecologica Scandinavica

36. Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic

2017 EvidenceUpdates

37. Maintenance agonist treatments for opiate-dependent pregnant women. (PubMed)

Maintenance agonist treatments for opiate-dependent pregnant women. The prevalence of opiate use among pregnant women can range from 1% to 2% to as high as 21%. Heroin crosses the placenta and pregnant, opiate-dependent women experience a six-fold increase in maternal obstetric complications such as low birth weight, toxaemia, third trimester bleeding, malpresentation, puerperal morbidity, fetal distress and meconium aspiration. Neonatal complications include narcotic withdrawal, postnatal

2013 Cochrane

38. Vaginal birth after caesarean section

) 7 - Fetal distress 600 (490–690) 7 - Malpresentation/breech 750 (600–860) 7 - (i) Australian review 32 ; (ii) International systematic review 7 Abbreviations: CI: Confidence interval; FTP: Failure to progress; CPD: Cephalo-pelvic disproportion 4 Intrapartum care Provide intrapartum care as per the Queensland Clinical Guideline Normal Birth. 37 Refer to the following sections for planned VBAC specific care. Queensland Clinical Guidelines: Vaginal birth after caesarean (VBAC) Refer to online (...) cannula • Group & hold, full blood count • One-to-one midwifery care • Continuous fetal monitoring • For intrapartum care: - Refer to QCG: Normal birth Augmentation • Discuss with obstetric team • Refer to QCG: Normal birth • Consider: - Supportive measures - Artificial rupture of membranes - Oxytocin infusion: ? Refer to IOL box Elective repeat CS (At 39-40 week, if clinically appropriate) No No Queensland Clinical Guideline (QCG): MN15.12-V4-R20 Vaginal Birth after caesarean section (VBAC

2015 Queensland Health

39. SMFM State of Pregnancy Monograph

SMFM State of Pregnancy Monograph SMFM State of Pregnancy MonographF irst recognized by the American Board of Obstetrics and Gynecologists in 1973, the subspecialty of Maternal-Fetal Medicine (MFM) grew from a need to care for increasingly complicated pregnancies and from emerging technologies that provided greater opportunity to evaluate and treat problems involving the fetus. MFM subspecialists are the leaders in high- risk obstetric care and serve as consultants to other obstetric care (...) providers. With additional years of subspecialty training after completion of residency, MFM subspecialists have advanced knowledge of the medical, surgical, obstetrical, fetal and genetic complications of pregnancy and their effects in both the mother and the fetus. The MFM subspecialist provides peer and patient education and performs research developing the most innovative approaches and treatments for obstetrical problems, thus promoting risk-appropriate care for complicated pregnancies. This 2nd

2015 Society for Maternal-Fetal Medicine

40. Safe Prevention of the Primary Cesarean Delivery

. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show (...) . In order to understand the degree to which cesarean deliveries may be preventable, it is important to know why cesareans are performed. In a 2011 population-based study, the most common indications for primary cesarean delivery included, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia ( ) ( ). Arrest of labor and abnormal or indeterminate fetal heart rate

2014 American College of Obstetricians and Gynecologists

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