Bunion

1) Disease Description (Causes and Symptoms)

• Definition: Refers to a condition in which the fetus does not assume the cephalic presentation (head down), which is standard at delivery (e.g., breech, transverse, or shoulder presentation). In most cases, vaginal delivery (spontaneous vaginal delivery) is difficult or carries increased risk.
• Causes and pathophysiology:
  • Fetal factors: Normal rotation may be difficult due to a small fetus, abnormalities (anencephaly, hydrocephalus, etc.), chromosomal abnormalities, and other factors.
  • Uterine and placental factors: The uterine cavity may become enlarged due to placenta previa, multiple pregnancy, or polyhydramnios; rotation may also be obstructed by uterine malformations, intrauterine adhesions, or tumors in the pelvic cavity.
  • Maternal factors: Problems with pelvic structure, such as a contracted pelvis.
  • Pathophysiologically, failure of fetal rotation delays or prevents engagement of the head, increasing the risk of umbilical cord compression and difficult labor during delivery.
• Main symptoms:
  • Usually asymptomatic. Abnormal fetal presentation is identified through examination (abdominal palpation or vaginal examination) or ultrasound.
  • Fetal movement may be felt in abnormal locations, such as above, beside, or below the navel.
• Prevalence: Rotation commonly occurs before 37 weeks of pregnancy, but by term, approximately 3–5% of fetuses remain in an abnormal presentation.

2) Treatment Methods (Standard Treatment · Medication · Procedures/Surgery · Lifestyle Management · Precautions)

• Observation (conservative management):
  • Before 37 weeks, spontaneous rotation is highly likely, so observation and follow-up are often performed.
• External Cephalic Version (ECV):
  • Timing: Generally attempted just before term (around 36–37 weeks).
  • Procedure: The fetal position is confirmed by ultrasound, and the presentation is manually rotated through the abdomen under fetal heart rate monitoring (CTG). Administration of a tocolytic (uterine relaxant, such as terbutaline) can increase the success rate and reduce discomfort.
  • Success rate: Approximately 40–60% overall (higher in women who have previously given birth). Complications are rare if the procedure fails, but they are possible.
  • Contraindications: Placenta previa, dangerous conditions in a multiple pregnancy, oligohydramnios, existing fetal distress (abnormal CTG), uterine malformation, bleeding, and other conditions.
  • Ultrasound and CTG, as well as preparation for an immediate cesarean section, are necessary before and after the procedure.
• Delivery planning:
  • Planned cesarean section: If breech presentation persists at term, many institutions recommend cesarean delivery for safety (especially in first-time mothers or when other risk factors are present).
  • Planned vaginal breech delivery: Considered only under limited conditions (experienced medical staff, appropriate estimated fetal weight, a specific type of breech presentation, adequate pelvic size, etc.). Most institutions prefer cesarean delivery for breech presentation at term.
• Medication and supportive care:
  • Tocolytics (to support ECV), local analgesia, sedation, or regional anesthesia (depending on the situation).
• Complication management and precautions:
  • ECV complications: Fetal heart rate abnormalities, placental abruption, rupture of membranes, and, rarely, emergency cesarean section.
  • Delivery complications: Umbilical cord prolapse, fetal injury, prolonged labor, and postpartum hemorrhage (when related conditions are present).
  • Before delivery, carefully monitor for changes in fetal movement and bleeding; seek immediate evaluation if fetal movement decreases.
• Prognosis:
  • If spontaneous rotation occurs before term, normal delivery is possible in most cases. Even when presentation remains abnormal at term, maternal and neonatal outcomes are generally favorable with appropriate management; however, the risk of neonatal complications due to breech presentation (such as hypoxia) may be relatively increased.

3) Outpatient Visit Checkpoints (Including What to Bring and Sample Questions)

• Items to bring (for visits and examinations):
  • Results or images from a recent obstetric ultrasound (fetal position, estimated fetal weight, placental location, and amniotic fluid volume).
  • A list of medications currently being taken (including prescriptions, OTC medications, and herbal medicines).
  • Previous delivery records (including whether there was a previous cesarean section) and surgical records.
  • Recent CTG results, if available, and materials confirming gestational age (last menstrual period or ultrasound).
  • A record of current symptoms, such as bleeding, changes in fetal movement, or fever.
• Information to tell the medical staff in advance during the outpatient visit:
  • Whether this is a multiple pregnancy, any previous surgery or uterine incision, current abdominal pain or vaginal bleeding, and pregnancy-related complications (such as hypertension or gestational diabetes).
• Possible examinations and procedures during the outpatient visit:
  • Ultrasound to check fetal presentation, placental location, and amniotic fluid volume; CTG if necessary.
  • If ECV is being considered, guidance on pre-procedure examinations, consent, and safety preparations.
• Items the patient may find useful to record in advance (including for use as sample questions):
  • Changes in fetal movement (frequency and intensity) and when they began
  • Whether there has been any recent vaginal bleeding
  • Previous delivery method and complications
  • Medications currently being taken (especially tocolytics, anticoagulants, etc.)

4) Examples of General Questions to Ask the Doctor

• What are the side effects of this medication (such as a tocolytic)?
• What is the success rate and risk of external cephalic version (ECV)?
• What is the next plan if ECV fails?
• If breech presentation persists, is a cesarean section necessary? Under what conditions is vaginal delivery possible?
• What complications can be expected with a cesarean section, and what is the recovery process like?
• Does the fetus need additional testing (a non-stress test, additional ultrasound, etc.)?
• What preparations are needed to protect the mother and newborn during delivery?

5) Examples of Condition-Specific Questions

• I am currently 37 weeks pregnant, and the fetus remains in breech presentation. Can external cephalic version (ECV) be attempted? (What are the chances of success and the risks if it is attempted?)
• I have a history of cesarean section. If the fetus is in breech presentation, please explain whether ECV or vaginal delivery is possible, or whether repeat surgery (cesarean section) is unconditionally necessary.

(Note: Fetal heart rate monitoring is required before and after ECV, and preparations must be in place for an immediate cesarean section. Selection criteria and policies may differ by hospital and medical staff, so please bring information about your ultrasound and obstetric history (multiple pregnancy, placenta previa, history of cesarean section, etc.) when you visit for consultation.)