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20

  1. 1. BREECH PRESENTATION & DELIVERY Panwad Rattanasrithong INT2
  2. 2. Definition & Clinical importance
  3. 3. DefinitionThe presentation that the fetus is inlongitudinal lie and its buttock enter thepelvis first
  4. 4. Incidence3-4% of singleton deliveries15% at 29 – 32 weeks
  5. 5. ETIOLOGYPrecipitating factor Gestational age Great parity / Multiple fetuses (uterine relaxation) Hydramnios / Oligohydramnios Hydrocephalus / Anencephalus Previous breech delivery Uterine anomalies / Pelvic tumors Placenta previa
  6. 6. Types of breech
  7. 7. Types of breechFrank breech : flexed at hips andextended at kneesComplete breech : flexed at hips andflexed at kneesIncomplete breech : one or both hipsare not flex and one or both feet or kneeslie below the breech
  8. 8. Diagnosis
  9. 9. Abdominal examination1st Leopold maneuver: ballottement2nd Leopold maneuver: large part3rd Leopold maneuver: movable4th Leopold maneuver: prominence
  10. 10. Vaginal ExaminationPalpable : both ischial tuberosities,thesacrum and the anusDDx : Face presentation (Mouth andMalar eminence)Position & Variety : Sacrum&Spinusprocess
  11. 11. Imaging Techniques Ultrasound CT MRI
  12. 12. Mechanism of delivery
  13. 13. Mechanism of deliveryDenominator
  14. 14. Mechanism of deliveryEngagementDescentInternal rotationLateral flexionExternal rotationBirth : breech body head
  15. 15. Mechanism of deliveryEngagement Descent
  16. 16. Mechanism of deliveryInternal rotation Lateral flexion
  17. 17. Mechanism of deliveryExternal rotation Birth : breech
  18. 18. Mechanism of delivery Birth : body head
  19. 19. Modes of delivery
  20. 20. Modes of deliveryCesarean sectionVaginal delivery Spontaneous breech delivery Assisted breech delivery (Partial extraction) Total breech extraction
  21. 21. Vaginal delivery
  22. 22. Vaginal delivery Entrapment of fetal head : Duhrssenincision Entrapment of fetal arm behind the neck(nuchal arm) Prolapse cord : complete – 5% ,footling-15%
  23. 23. Duhrssen incision
  24. 24. Vaginal deliveryUnfavorable pelvis Gynecoid & anthropoid : favorable Platypelloid & Android : unfavorable
  25. 25. Vaginal deliveryHyperextension 5 % in term breech presentation Result : Injury to C spinal cord Marked hyperextension : C/S
  26. 26. Vaginal deliveryLabor induction & Augmentation No significant mortality and Apgarbetween infant with induced vs spontanous] Oxytocin Amniotomy CT confirm adequate pelvis
  27. 27. Vaginal deliveryManagement of labor Establish : Membranes,labor,Fetalcondition,UC Notified nursery Stage of Labor : Cx , Eff , Station ,Presentation Fetal Monitoring : FHR q 15 min (most continue EFM) PV check cord prolapse & FHR q 5-10min (MR)
  28. 28. Vaginal deliveryMethods of Vaginal delivery Spontaneous breech delivery Partial breech extraction Total breech extraction
  29. 29. Vaginal deliveryAssisted Breech Delivery
  30. 30. Vaginal deliveryThe posterior hip of frankbreech is delivering
  31. 31. Vaginal delivery The anterior hip has now delivered and external rotation has occurred. The fetal thighs remain in flexion with extension knees.
  32. 32. Mode of deliveryDelivery of thelegs by placingthe fingersparallel withmedial aspect ofthe femur anddisplacinglaterally and awayfrom midline
  33. 33. Mode of deliveryDelivery of the body.
  34. 34. Delivery of the shoulder Cats paw method Classical method Lovset ‘s method
  35. 35. Cats paw method
  36. 36. Cats paw method
  37. 37. Classical Method
  38. 38. Lovset’s Method
  39. 39. Partial breech extraction or breech assistingDelivery of the aftercoming head Mauriceau-Smellie-veit maneuver Prague maneuver Piper forceps
  40. 40. Mauriceau-Smellie-Veit Maneuver
  41. 41. Prague maneuver The back of the fetus fail to rotate to the anterior
  42. 42. Piper Forceps
  43. 43. Total breech extractionIndication 1. Prolong second stage of labor 2. Twin 3. Maternal disease 4. Prolapse cord 5. Fetal distress
  44. 44. Total breech extractionContraindication 1. Cervix not fully dilated 2. CPD
  45. 45. Total breech extractionThe hand is introduced through the vagina&both feet of the fetus are graspedGentle traction the feet through the vulvaBreech appears at the vulva, gentletraction until the hips are deliveredassisted breech delivery
  46. 46. Completebreechextractionbegins withtraction on thefeet and ankles.
  47. 47. continues withtraction on thethighs
  48. 48. the scapulasbecomesvisible and thebody rotates,usually to theside of themother
  49. 49. Cesarean sectionRecommendation Large fetus Contraction or unfavorable shape of pelvis Hyperextended head Delivery is indicated but not in labor Uterine dysfunction Incomplete or footling presentation
  50. 50. Cesarean sectionRecommendation Healthy preterm Severe fetal growth restriction Previous perinatal death or newborn complication of birth trauma A request for sterilization Lack of an experienced operator
  51. 51. Morbidity & MortalityMaternal Injuries Risk : Operative intervention Manipulations : Risk infection Intrauterine maneuvers : Rupture of theuterus +/- lacerations of Cx Extensions of the episiotomy Uterine atony , Postpartum hemorrhage
  52. 52. Morbidity & MortalityPerinatal Morbidity & Mortality Preterm delivery & low birth weight & IUGR Prolapse cord Birth aphyxia Fetal Injuries Fx of humerous and clavicle Fx of femur Hematomas of sternocleidomastoid Separation of epiphyses of scapular,humerus or femur Brachial plexus Avulsion of upper C-spine Skull Fx , intracerebral injury
  53. 53. Intracerebral haemorrhage
  54. 54. Birth asphyxia
  55. 55. Version
  56. 56. VersionExternal cephalic versionInternal podalic version
  57. 57. External Cephalic Version
  58. 58. Thank you for attention

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