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Breech

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  • 1. International University of Africa Faculty of Medicine and Health Sciences Breech 2 Presented by:- Dr. Alwaleed M.Alfaki Gya. & Obs. www.doctor.sd
  • 2. Breech
    • Incidence:-
    • 3-4% at term
    • Type:-
    • Complete breech “flexed breech ”:-
    • Hips and knees are both flexed
    • 25% of cases
    • Common in multiparous women
    • Cord prolapse is common
    www.doctor.sd
  • 3. 2. Incomplete breech Extended or frank breech
    • The legs are fully flexed at the hips and extended at the knees
    • 65% of cases Common in PG (-rigid abdominal wall -good uterine tone)
    • 3)Footling breech
    • Occurs in 10% of cases
    • High incidence of cord prolapse
    • 4)Knee presentation
    • -rare
    www.doctor.sd
  • 4. Causes of breech
    • Prematurely is the commonest cause “30-40% at 20__25 weeks”
    • “ 15%at 32 weeks “.
    • Extended leg
    • Fetal anomalies( hydrocephalus – anencephaly) .
    • Multiple pregnancy.
    • IUFD
    • Short cord
    • Placenta previa and cornual insertion of the placenta
    www.doctor.sd
  • 5.
    • Uterine abnormalities (septate, bicornuate ) fundal myoma
    • Pelvic tumors
    • Poly and oligohydramnios.
    • Multiparty and previous breech delivery
    • Idiopathic
    www.doctor.sd
  • 6. Diagnosis
    • Abdominal examination reveals the head (smoother rounder, harder and palatable) at the fundus.
    • Fetal heart is best heard above the umbilicus on the side of the back.
    • On vaginal examination the soft-irregular breech can be felt. In complete breech the feet can also be felt.
    www.doctor.sd
  • 7. Investigation
    • Ultra sound scan:-
    • Confirm the diagnosis
    • Exclude placenta previa
    • Lateral X-Rays abdomen:-
    • Confirm diagnosis and type of breech
    • Reveals major skeletal malformations
    • Reveals degree of flexion of the head
    • Pelvimetry
    www.doctor.sd
  • 8. Complication of breech
    • Fetal complications :-
    • Are from Asphyxia- trauma and congenital malformation.
    • Perinatal mortality at least 5 times that of cephalic presentation
    • Fetal Asphyxia due to:-
    • Retained after coming head (>10 min)
    • Cord prolapse compression by after coming head
    • Premature respiration
    • Premature separation of the placenta
    www.doctor.sd
  • 9.
    • trauma
    • Fast delivery of the head before moulding with compression and decompression of the head leads to intracranial Hge, tentorial tear, Fracture skull borne
    • Dislocation of cervical spine
    • Fracture and epiphyseal separation of femur. Humorous and clavicle
    www.doctor.sd
  • 10.
    • Brachial plexus palsy and trans section of the cord (erb’s palsy).
    • Sternomastoid muscle rupture & haematoma.
    • Rupture of abdominal viscera.
    • ↑ incidence of malformation
    • Maternal complication :-
    • genital track laceration
    • Postpartum haemorrhage
    • Danger of emergency anaesthesia and C/S
    www.doctor.sd
  • 11. Management (mode of delivery)
    • Elective caesarean section.
    • Breech presentation associated with any other obstetric adverse factors is generally delivered by C/S :-
    • fetal weight >3.5kg
    • footling breech
    • Hyperextension of the head
    www.doctor.sd
  • 12.
    • - Any degree of pelvic contraction & abnormal shape
    • Associated pregnancy complications like APH, PIH diabetes . BOH
    • External cephalic version:-
    • Changing the breech to cephalic by trans abdominal manipulation.
    • Usually done after 36 week.
    • Risks are 1% mortality –rupture memebranes with preterm labour-abruptio placenta- cord accident- feto maternal transfusion- rupture uterus )
    www.doctor.sd
  • 13.
    • Contraindication:- (indication of c/s –APH- PIH-scar uterus- multiple pregnancy- congenital malformation of the uterus –B.O.H- elderly PG –rupture membrane - IUFD-IUGR.
    • Cause of failure of ECV. Are (extension of the les –large fetus. Undiagnosed twins- short cord-scanty liquor-irritable uterus- uterine anormalies –rigid abdominal wall- obesity –engaged breech).
    • Vaginal breech delivery
    • 1. spontaneous ,
    • 2. assisted breech delivery
    • 3. breech extraction)
    www.doctor.sd
  • 14. 1/ assisted breech delivery
    • Delivery particularly of the head is usually assisted to a varying degree this involves gentle manipulation to control and guide the fetus during the mother’s expulsive effort so that the delivery is affected with minimum of trauma and maximum of safety .
    www.doctor.sd
  • 15.
    • Acceptable if:-
    • Pelvis normal in size and in shape
    • Fetal weight about 3.5kg or less
    • Flexed head
    • No other obstetric complication
    • Should be under taken in fully equipped hospital
    • Fist stage :-managed as high risk labour (NPO- I.V fluid –pain relief- maternal & fetal monitoring)
    • Second stage :- lithotomy or modified lithotomy position –episiotomy.
    www.doctor.sd
  • 16.
    • Delivery of after coming head .
    • 1- forceps:- more safe –because of controlled delivery of head
    • 2- Buns- marshall’s technique :-
    • The baby is grasped by the ankles with maintained traction and is swung through a wide arc towards the mother abdomen.
    • 3- jaw flexion- shoulder traction (mauriceau –smellie veit technques -not recommended –traction may cause brachial –plexus injury)
    www.doctor.sd
  • 17.
    • 2/ spont breech delivery:-
    • - Should not be allowed
    • Occur rarely except in multiparous patient, in preterm labour
    • Carry high perinatal mortality & morbidity.
    www.doctor.sd
  • 18.
    • 3/ breech extraction:-
    • Delivery of the fetus with no assistance from the mother
    • Indication :- in second stage of labour
    • -fetal distress
    • Cord prolapse
    • Delay of delivery of second twin
    • Maternal distress
    • Should be done in the theatre & only if:
    • No Cephalo pelvic disproportion
    • Cervix fully dilated
    • Patient adequately anaesthetized
    • Enough liquor. To allow manipulation
    www.doctor.sd