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BreechPresentation     Lucy Pettit
Aims and Objectives At the end of the session, we should be  able to: -   Diagnose a breech presentation   Carry out a ...
Incidence 3-4% of fetus present by breech at term 7% at 32 weeks 25% at 28 weeks 20% diagnosed initially in labour
Causes / Risk Factors   Primigravida   Uterine anomalies   Uterine fibroids   Pelvic anatomy   Fetal anomalies   Mul...
External Cephalic Version Best evidence states that E C V should be  offered late in pregnancy Success rate increased wi...
Diagnosing a Breech Palpation:     The fetal head can be palpated at uterine      fundus Auscultation:     The fetal h...
Types of Breech    Frank   Complete   Footling
Vaginal Examination extended (frank) presentation:    The ischial tuberosities, sacrum anus and/or     genitals may be p...
Emergency Care Call for help – midwifery colleagues/8000 Support & explanations for parents Take blood for group/hold, ...
Vaginal Breech Birth in Hospital Explain procedure to patient Legs in lithotomy Empty bladder Confirm full dilatation/...
Breech Delivery The essence of the vaginal breech delivery is allowing as      much spontaneous delivery by uterine action...
Breech Delivery                  The cervix should be                  fully dilated and the                  fetal anus v...
Breech Delivery                  The woman should                  be in lithotomy                  position.
Breech Delivery                  Delivery of the                    breech should be                    ‘hands off’       ...
Breech Delivery                  Ensure that the fetal                  back rotates                  uppermost by        ...
Breech Delivery The fetus should be allowed to hang once the legs and abdomen have emerged until the wings of the scapula ...
Lovset’s Manoeuvre               Grasp the fetus around the                 bony pelvis with the                 thumbs ac...
Lovset’s ManoeuvreThe elbow will appear below  the symphysis pubis and  the arm is delivered by  sweeping it across the  f...
Breech Delivery                  Allow the fetus to hang                    from the vulva until                    the na...
Emergency Checklist      Em ergency Check list      Vaginal Br eech Deliver y                                             ...
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Breech presentation

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Lucy Pettit, Midwife, Wanganui

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Breech presentation

  1. 1. BreechPresentation Lucy Pettit
  2. 2. Aims and Objectives At the end of the session, we should be able to: -  Diagnose a breech presentation  Carry out a breech delivery  Be familiar with the manoeuvres if assistance is required
  3. 3. Incidence 3-4% of fetus present by breech at term 7% at 32 weeks 25% at 28 weeks 20% diagnosed initially in labour
  4. 4. Causes / Risk Factors Primigravida Uterine anomalies Uterine fibroids Pelvic anatomy Fetal anomalies Multiple pregnancy Preterm labour Oligohydraminos / polyhydramnios Grand multiparity Fetal death
  5. 5. External Cephalic Version Best evidence states that E C V should be offered late in pregnancy Success rate increased with:  multiparity  adequate liquor  station of breech above the pelvic brim
  6. 6. Diagnosing a Breech Palpation:  The fetal head can be palpated at uterine fundus Auscultation:  The fetal heart sounds may be heard above umbilicus
  7. 7. Types of Breech Frank Complete Footling
  8. 8. Vaginal Examination extended (frank) presentation:  The ischial tuberosities, sacrum anus and/or genitals may be palpated. In addition, there may be meconium staining of the examiner’s fingers complete presentation:  The feet of the fetus may be palpated with the buttocks
  9. 9. Emergency Care Call for help – midwifery colleagues/8000 Support & explanations for parents Take blood for group/hold, FBC Monitor fetal heart Monitor maternal vital signs Prepare IV Normal Saline – cannulation 16g Transfer to theatre – if not  Prepare for vaginal delivery
  10. 10. Vaginal Breech Birth in Hospital Explain procedure to patient Legs in lithotomy Empty bladder Confirm full dilatation/presentation/station Infiltrate perineum with 10mls Lignocaine1% Consider episiotomy when presenting part is on the perineum Perform necessary manoeuvres for the delivery of breech Record times of procedures / manoeuvres, designate a scribe
  11. 11. Breech Delivery The essence of the vaginal breech delivery is allowing as much spontaneous delivery by uterine action and maternal effort as possible Operator intervention should be limited to the manoeuvres. Nuchal arms are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions.
  12. 12. Breech Delivery The cervix should be fully dilated and the fetal anus visible on the perineum for active second stage.
  13. 13. Breech Delivery The woman should be in lithotomy position.
  14. 14. Breech Delivery Delivery of the breech should be ‘hands off’ Legs and abdomen are born spontaneously.
  15. 15. Breech Delivery Ensure that the fetal back rotates uppermost by carefully grasping the fetal pelvis with fingers & thumbs
  16. 16. Breech Delivery The fetus should be allowed to hang once the legs and abdomen have emerged until the wings of the scapula are seen.
  17. 17. Lovset’s Manoeuvre Grasp the fetus around the bony pelvis with the thumbs across the sacrum. The fetal back should then be turned through 180 degrees until the posterior arm comes to lie anteriorly…….
  18. 18. Lovset’s ManoeuvreThe elbow will appear below the symphysis pubis and the arm is delivered by sweeping it across the fetal body.The manoeuvre is repeated in reverse to deliver the other arm.
  19. 19. Breech Delivery Allow the fetus to hang from the vulva until the nape of the neck is visible. Then carry out Mauriceau-Smellie- Veit manoeuvre
  20. 20. Emergency Checklist Em ergency Check list Vaginal Br eech Deliver y Bradma Procedure Dat e ________________ Tim es Names of pract it ioner s • Emergency Bell ……………. pr esent • 8000 obstetric emergency call made/ Paediatrician called ……………. • Notify theatre of potential emergency LSCS ……………. • Delivery trolley with Wrigley/NB forceps ……………. • Commence CTG tracing ……………. • IV cannula inserted ……………. • Mother in left lateral or lithotomy ……………. • Maternal pushing when fully …………… • Descent of fetus ‘hands off’ ……………. • Evaluate for episiotomy when fetal anus at fourchette ……………. • Deliver legs if extended by flexing the fetal knees ……………. • Rotate to keep back anterior ……………. • Any contact with fetus only with hands on fetal pelvis (avoid soft abdomen) …………….. • When scapulae visible spontaneous delivery of arms …………….. • Lovset’s manoeuvre (if necessary) …………….. • Support trunk (fetus along dorsal aspect practitioner arm) …………….. • Burns-Marshall or Mauriceau-Smellie-Veit manoeuvre to deliver head slowly ……………. • Delivery time ……………. • Cord blood sample for Ph/lactate ……………. • Third stage by active management …………….. • Documentation …………….. Photocopy this checklist and place in patient’s notes with patient label on top of page. Use as reference for more detailed clinical notes. Remember to sign the copy for the clinical notes. Please wipe clean checklist once copied and return to delivery room

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