25 - Breech Presentation and Multiple Pregnancy: Obstetrical Aspects Anaesthetic Management

Abstract

SUMMARY Breech presentation and multiple pregnancy increase perinatal mortality and neonatal morbidity. They share similar problems, especially prematurity, asphyxia and intrapartum trauma. Intraventricular haemorrhage is a major neonatal risk. Obstetric management focuses on the prevention of prematurity and delivery by the most favourable route. As a result, the incidence of caesarean section has increased. Many studies affirm the benefits of regional anaesthesia for the high-risk pregnancy, and lumbar epidural block offers titratability, excellent maternal pain relief and lack of fetal depression. The maintenance of uteroplacental flow requires measures to avoid hypotension, for example, selective epidural block and careful attention to maternal hydration and position during labour and delivery. Fetal oxygenation improves with increasing maternal fractional inspired oxygen. Subarachnoid block may be beneficial in breech delivery, especially in emergency situations, but is less satisfactory in multiple pregnancy. Regional techniques avoid the maternal and fetal risks of emergency general anaesthesia. When general anaesthesia becomes necessary, steps to reduce maternal aspiration, improve fetal oxygenation and relax the uterus for intrauterine manipulations take precedence. Ultimately, the successful management of breech presentation and multiple pregnancy requires a team approach by obstetricians, anaesthetists and neonatologists.