Oxford Handbook of Midwifery (43 page)

• Grade 3.
  The placenta partially covers the internal cervical os but not in a central position. Bleeding is likely to be severe, particularly in late pregnancy when the cervix starts to efface and dilate. Vaginal delivery is
  

  not possible as the placenta precedes the fetus.
  

• Grade 4.
  The placenta is completely covers the internal cervical os and the risk of torrential haemorrhage makes caesarean section essential to save the mother and the fetus.
  

  Management depends on the amount of bleeding and the gestation. Admit the mother to a consultant unit for her condition to be assessed.
  

  Mild to moderate bleeding
  

• Abdominal examination.
  
• Cardiotocograph to monitor fetal condition.
  
• Commence intravenous infusion.
  
• FBC and cross-match units of blood as per protocol.
  
• Ultrasound to confirm fetal well-being and position of placental border.
  
• Timing and mode of delivery will depend on the general condition of the woman, the extent of bleeding and the gestation.
  

  Profuse bleeding
  

• Commence intravenous fluid immediately and transfuse blood as soon as it becomes available.
  
• Once the woman’s condition is stable, prepare her for emergency caesarean section.
  

ANTEPARTUM HAEMORRHAGE

159

Placental abruption

Causes

Presents as continuous abdominal pain, sometimes with uterine contrac- tions superimposed, with or without vaginal bleeding. Bleeding may be concealed inside the uterus, apparent as vaginal loss or both.

There may be symptoms of severe shock, disproportionate to the amount of blood lost. The pain may be localized if the abruption is small, and is felt over the site of the abruption. The uterus is very tender on palpation and hard ridges may be felt. The fetal heart beat may be absent.

Pain is caused by:

Management

antenatal care will be consultant led with more frequent attendance.

• Commence intravenous infusion
  
• FBC and cross-match as per protocol
  
• Commence blood transfusion as soon as blood is available
  
• Provide pain relief
  
• Perform a clotting screen and Kleihauer test
  
• Perform cardiotocography to monitor the status of the fetus
  
• Prepare for induction of labour or caesarean section as the fetal and maternal condition dictates.
  

  Complications due to placental abruption are:
  

1. Potdar N, Navti O, Konje JC (2009). Antepartum haemorrhage. In: Warren R, Arulkumaran S (eds)
   Best Practice in Labour and Delivery
   . Cambridge: Cambridge University Press, pp. 141–44.
   
2. Lewis, G (ed.) (2007).
   The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to Make Motherhood Safer
   —
   2003–2005
   . The 7th report on Confidential Enquires into Maternal Deaths in the United Kingdom. London: CEMACH.
   

   CHAPTER 9
   Pregnancy complications
   

   160‌‌
   

   Breech presentation
   

   In this presentation the fetus is in a longitudinal lie with the buttocks entering the pelvis first.
   

   Incidence
   

   • At 20 weeks: 40%
     
   • At 28 weeks: 15%
     
   • At 34 weeks: 6%
     
   • At 40 weeks: 3%.
     

     Classification
     

   • Breech with extended legs:
     70%. The legs are straight and the feet may lie on either side of the head, acting as a splint and making it difficult to ballot the head.
     
   • Complete or flexed breech:
     25–29%. The knees are bent and ankles crossed so the feet lie close to the buttocks.
     
   • Footling breech:
     rare. From the flexed breech one foot falls downwards to present over the cervical os. The foot may slip through as the cervix dilates in labour.
     
   • Knee presentation:
     very rare. From the flexed breech one knee falls downwards over the cervical os.
     

     Causes
     

   • Preterm labour.
     
   • Polyhydramnios.
     
   • Multiple pregnancy—the second twin is often a breech presentation.
     
   • Placenta praevia—the placenta takes up room in the lower uterus, leaving less space for the fetal head to present.
     
   • Contracted pelvis—not enough room for the fetal head to engage in
     the pelvis.
     
   • Multiparity.
     
   • Fetal or uterine abnormality.
     

     Antenatal diagnosis
     

   • On abdominal palpation the head is felt at the top of the uterus and it ballots easily unless splinted by extended legs.
     
   • The breech is smaller, softer, and more irregular than the hard smooth, rounded head.
     
   • Fetal heart sounds are heard above the level of the maternal umbilicus.
     

     Management
     

   • If breech presentation is diagnosed at the 36-week antenatal visit, offer the mother external cephalic version to convert the breech to head presenting. This is arranged to take place as close to term as possible, commonly at 38 weeks’ gestation.
     ¹
     
   • A 50% success rate has been reported for the procedure, depending on the skill and experience of the operator.
     ²
     
   • External cephalic version should be performed by an obstetrician or specialist trained midwife in a hospital setting.
     

BREECH PRESENTATION

161

Contraindications