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Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

Breech Delivery Vaginal Breech (378)

Please report any inaccuracies or issues with this guideline using our online form

The incidence of breech presentation is 25% at 28 weeks, 16% at 32 weeks and 3-4% at term. The authors of the term breech trial recommended “the best method of delivering a complete or frank breech singleton at term is by planned lower segment caesarean section”. Nevertheless there are women with a breech presentation at term who will make an informed choice to have a trial of vaginal breech delivery.  There is no good evidence to support that caesarean section is the safest mode of delivery for the preterm breech.  There are also women who will present in advanced labour with an undiagnosed breech presentation, for whom caesarean section may not be an option.

IT IS THERFORE IMPORTANT THAT CLINICIANS ARE FAMILIAR WITH TECHNIQUES FOR ACHIEVING SUCCESSFUL VAGINAL BREECH DELIVERY

The same manipulations are employed when delivering a breech or a Caesarean section. Master them when doing CS for Breech presentations.

Management of Vaginal Breech Delivery: In women who decline or are unsuitable for Caesarean section Types of Breech

There are four types of breech presentation. They are determined by the way in which the fetal legs are flexed or extended, and these have implications for the birth

  • Complete or Flexed Breech: The flexed breech occurs more commonly in the multigravid woman. Flexed breech is when the fetus sits with the thighs and knees flexed with the feet close to the buttocks. (see Diagram A)
  • Frank or Extended Breech: This is the commonest type of breech presentation and occurs most frequently in the primigravid woman towards term: the fetal thighs are flexed, but the legs are extended at the knees and lie alongside the trunk, the feet being near the fetal head. (see Diagram B)
  • Footling presentation: This type of breech is more likely to occur when the fetus is preterm, but is relatively rare. Footling breech is when one or both feet present below the fetal buttocks, with hips and knees extended. There is increased risk of cord prolapse.
  • Knee presentation: This is the least common. This occurs when one or both knees present below the fetal buttocks, with one or both hips extended and the knees flexed.

Management of First Stage of labour

On admission

  • Confirm breech presentation.
  • Clinical assessment of the fetal size
  • Assess whether pelvis seems to be adequate.
  • Ultrasound by a competent practitioner is useful to:
    • assess the type of breech
    • Locate the placenta,
    • Assess size of the fetus (unless AC performed within last 14 days)
    • Determine the attitude of the fetal head.
    • Fetal heart activity
    • Amniotic fluid volume
    • Whether neck is extended or not

N.B There should be no hyperextension of the fetal head. If present: explain to woman what this means. This is a contra-indication to attempting vaginal birth.

Following above assessment:

  • Discuss management options and confirm that the mother still wishes to have a vaginal breech delivery.
  • Obtain written consent including options of emergency interventions (Breech extraction and CS)
  • Inform the consultant obstetrician on call
  • Inform on-call anaesthetist / paediatric staff
  • Obtain IV access: 14g cannula
  • Offer epidural anaesthesia (not essential but helpful)
  • If membranes  rupture  spontaneously,  vaginal  examination  is  required  to  exclude umbilical cord prolapse.
  • If membranes are still intact then amniotomy should only be performed  for usual indications.
  • Continuous fetal monitoring should be used.
  • Fetal blood sampling can be performed from the fetal buttocks. The indications,  technique  and interpretation used should be the same as for cephalic presentations.
  • Oxytocin may be used with caution; after discussion with senior obstetrician; usual regime depending on parity.

Management of Second Stage:

Ideally a consultant obstetrician with experience of vaginal breech delivery should be present for the management of the second stage if time allows.

Basic principles:

  • A scrubbed assistant should be present if possible
  • Avoid handling the breech as it descends until leg manipulation required
  • Ensure good maternal effort
  • Do not touch the cord
  • Keep the sacrum anterior
  • Empty bladder
  • Begin active pushing when breech has descended to the pelvic floor.
  • Delay Lithotomy position until anus is visible over the fourchette.
  • Consider episiotomy at this time.
  • Allow spontaneous rotation to sacrum anterior position.
  • If legs extended, deliver legs by applying pressure in the popliteal fossa to flex the legs at the knee joint.

  • As the trunk descends with maternal effort, the tip of the scapula of the anterior shoulder becomes visible. The anterior arm should be delivered by splinting the humerus between 2 fingers. The other shoulder should rotate spontaneously to allow similar delivery of the other arm.
  • If the arms are extended or a nuchal arm is diagnosed Lovsett’s manoeuvre should be used Apply gentle traction using a femero-pelvic grip and deliver one arm by clockwise rotation to the oblique, followed by counter clockwise rotation to the oblique to deliver the other arm.

 

N.B Lovsett is not a routine part of a vaginal breech delivery

  • Support the baby as the head engages.
  • Use Mauriceau-Smellie-Veit (MSV) manoeuvre to complete delivery. The MSV manoeuvre encourages flexion of the fetal head. Place one hand above the fetus with one finger on the fetal occiput and one finger on each of the fetal shoulders. The other hand should be placed below the fetus and 2 fingers should be placed on the maxillae (not in the mouth). Some practitioners use their 2nd and 4th fingers for this and place their middle finger under the chin for triangular stability. The fetal body is raised upward in an arc completing delivery

 

Application of Forceps to After Coming Head

In up to 20% of cases forceps may be required to deliver the fetal head.

This is not as difficult as it might appear. Practise on a manikin is advised to become familiar with the technique.

  • Do not panic
  • The head is generally direct OA or no more than 15° left or right.
  • Assistant should gently lift and support the baby without undue traction. Its body can be wrapped in a towel to keep it warm
  • Select Mid Cavity forceps, such as Simpsons. Do Not use Wrigley’s.
  • Apply Forceps using a standard approach. Once the first blade is applied any lateral deviation can usually be corrected to DOA.
  • Once the forceps are applied, check application and lock as next contraction commences
  • Gentle downward traction
  • Start upward traction once chin on perineum (evaluate for episiotomy if not already done; usual care and angulation)
  • Controlled and slow delivery of head
  • Transfer baby to waiting paediatric team
  • Take a cord PH
  • Deliver placenta and repair perineum
  • Record Comprehensive note

Editorial Information

Last reviewed: 30/04/2015

Next review date: 31/12/2022

Author(s): Julie Murphy.

Version: 3

Approved By: Obstetrics Clinical Governance Group

Document Id: 378

References

Images From:

www.manbit.com/images/f14-2a.gif

www.who.int/reproductive-health/impac/procerdures/breech

Seeds JW. Malpresentations. In: Gabbe SG, Niebyl JR, Simpson JL, editors. Obstetrics: normal and problem pregnancies. 2nd ed. New York: Churchill Livingstone, 1991:5 3 9-72.

Baskett TF. Essential management of obstetric emergencies. 2nd ed. Bristol: Clinical Press, 1991:126-3 5.

Emergencies Around Childbirth, A handbook for midwives. Edited by Maureen Boyle: Radcliffe medical Press, 2002.