nsg

1. Mittal college of
nursing Ajmer
Topic= mal presentation ( breech presentation
)
Subject = obstetric and midwifery
Presented by ,
Miss Rekha rawat
Bsc. Nursing 4h year
Presented to ,
Mrs. Snehlata parashar
Lecturer of obg.and
gyne.Submit date =

2. INTRODUCTION
•FETAL PRESENTATION = It is refers
to the part of the fetus that is
overlying the maternal pelvic inlet.
•MAL PRESNTATION =Except vertex
,all are considered malpresentation.
•Mal position= abnormal positioning
of fetus at the time of delivery .

3. THE
MALPRESENTATIONS
ARE•(1) occipito posterior position
•(2) Face presentation
•(3) Brow presentation
•(4) Breech shoulder
•(5) Compound presentation
•(6) Unstable lie

4. Occipito posterior
presentation
Face
presentation

5. Brow
presentation
Shoulder
presentatio
Compound
presentation

6. DEFINITIO
N
Breech Presentation is the Presentation in which the
Fetus in a longitudinal lie with the buttocks or feets
closet to the cervix .

7. INCIDENC
E
*The percentage of breech delivery decrease with
advancing gestational age from 22-25% of birth
prior to 28 weeks.
*3-4% of fetus present by breech at term
*5% at 34 weeks , usually 3 in 100 (3%)
*20% at 28 weeks.
*20% diagnosed initially in labor.
*The higher incidence of breech in earlier weeks of
pregnancy.

8. ETIOLO
GY
1=MATERNAL FACTORS…….
[A]Grand Multipara
[B] Uterine Abnormalities[Bicorn ate septate
uterus]
[c] fibroid uterus
[D]Contracted Pelvis ,Multiple pregnancy
2=FETAL FACTORS…..
[A] Prematurity

9. Bicorn ate
septate uterus
Anencephaly

10. CONT.,,,,,
[B] Macrosomia
[c]Fetal Anomalies[Hydrocephalus ,
Anencephaly]
[E] Twin pregnancy
[F] Fetal death
[G] Extended legs

11. CONT.,,,3= PLACENTAL,AMNIOTIC FLUID FACTORS…..
[A] Placenta Previa
[B] oligohydramnios
[C] Polyhydramnios
[D] Nuchal cord
[E] Short cord
[F] Trisomy

12. TYPES,
,,,,1=COMPLETE BREECH PRESENTATION
More common type 25%
More common in multipara women
Attitude= full flexion
Thigh are flexed on
the abdomen and the
legs are flexed at the knees.
The presenting part is
buttocks and feet .

13. CONT.,,,
B =INCOMPLETE BREECH PRESENTATION
1= FRANK BREECH
Attitude flexed
Thigh flexed on the trunk
Legs Extended on the knee Joint.
Presenting part Buttocks ,
External Genitalia .
More common in primi =70%

14. CONT.,,,
2=FOOTLING BREECH[10-30%]
Both the thigh and legs are partially extended bringing
the legs to present at the brim.
*Foot is the lower part .
3=KNEE PRESENTATION
Thigh are extended but the knees are flexed ,bringing
the knees down to the brim

16. POSITION

17. DIAGNOSIS
1= CLINICAL
A= ABDOMINAL PALPATION
a= Fundal grip _ a smaller ,harder,
more mobile , round , ballot able
head can be felt in the fundus.
B=lateral grip_ the back on one
Side and limb on the opposite
Side of the abdomen . aa

19. A
c= pelvic grip
Empty as soft irregular
Buttocks do not engage
Well like vertex.

20. CONT.,,,,
B=AUSCULTATION
Usually FHS heard above the level of the
umbilicus . however in frank breech it may be
heard at or below the level of the umbilicus.
C= VAGINAL EXAMINATION

21. 2=SONOGRAP
HY
3=RADIOLOGY
4=HORMONAL TESTING

22. MECHANISM OF
BREECH
• lie is longitudinal lie
• Attitude complete flexion
• Presentation breech
• Lt.sacro anterior position
• Denominator sacrum
• Presentig part anterior
Buttocks [left]

23. DELIVERY OF
BUTTOCKS
1=Engagement
2=Decent 3= flexion
4=Internal rotation of buttocks
5=lateral flexion
5= crowing
6= Restitution
7=Delivery of buttocks

24. DELIVERY OF
SHOULDER
1=Engagement
2=Decent
3=Internal rotation
4=lateral flexion
5=Restitution
6=delivery of shoulder

25. DELIVERY OF
HEAD1=Engagement
2= Decent
3=Internal rotation
4= flexion
5= delivery of head

26. COMPLICAT
ION
*Impacted breech Fetal hypoxia
*Cord prolapse Intra cranial
*Birth injuries hemorrhage
* Erb s palsy Maternal
trauma
*Trauma Premature
separation

27. MANAGEMENT
**ANTENATAL MANAGEMENT
• Identify complicating factors through
sonography
1=EXTERNAL CEPHALIC VERSION =
Manipulating process through change lie and
make a favorable pole to the lower pole of
uterus
• Steps=forward movement.
• Time =After 36 weeks.

28. Extern
al
cephali
c
version

29. CONT …
*Indication = breech presentation
transverse lie
*Advantages = spontaneous delivery
reduce LSCS ,Reduce maternal
and fetal mortality.

30. CONT….
Contraindication =
Antepartum hemorrhage , fetal causes
Multiple pregnancy , Ruptured membrane
Contracted pelvic ,obstetric complication .
Complication =
Umbilical cord entanglement , placenta abruption
Preterm labor , premature rupture of membranes

31. CONT.
2 =ELECTIVE CESAREAN SECTION
•In which the operation pre arranged time
during pregnancy.
•INDICATION == Big baby , small baby ,
Fetal distress, hyperextended legs,
footling presentation, IUGR

32. 3=VAGINAL BREECH
DELIVERYINDICATION = Average fetal weight
flexed fetal head
Adequate pelvic
Without complication of
medical, obg.
MANAGEMET ACCORDING TO THE STAGE =
FIRST STAGE = 1 Vaginal examination
2 check vital sign , FHS ,Empty
bladder

33. CONT.
4= Maintain partograph .
5 =Assess fetal and progress of labor .
6= Give adequate analgesic .
*Morphine sulphate 10mg IM
* pethidine hydrochloride 75-100 Mg IM
* OTHER 50% Nitrous oxide +50% oxygen
through inhalation..
7=Reduce anxiety and fear of pain

34. CONT.
SECOND STAGE =
There are three methods of vaginal breech
delivery :
SPONTANEOUS (10%)
Expulsion of fetus occurs with very little
assistance.
ASSISTED BREECH DELIVERY
The delivery of fetus Is by assistance from the
beginning to the end.
These should be conducted by a skilled

35. STEPS
*Positioning
*Antiseptic cleaning
*Encourage the patient bear down the expulsive force
1*Delivery of buttocks
2*Delivery of Arm =
the assistant is to place a hand over the fundus and keep
a steady pressure during uterine contraction to prevent
extension of the arm .
Soon, the anterior scapula is visible delivered the arm.
3*Delivery of head =this is the most crucial stage of the
delivery
The time between the delivery of umbilicus to mouth
should preferably be 5-10 min.

36. A=BURNS MARSHALL
METHOD
• BABY: Allow to hang by its weight
• ASSISTANT : Downward , backward
,suprapubic pressure pressure to
promote head flexion
• RIGHT HAND : Grasp ankle with a
finger in between (when nape of neck
is visible under pubic arch )
• Trunk is swung upward ,forward till
mouth is cleared off the vulva
• Depress the trunk to deliver the rest
of hand
• LEFT HAND : Guard the perineum
,face ,brow.

37. 2=FORCEPS DELIVERY
OF HEAD
• BABY: Allow to hangs by its
weight
• ASSISTANT : Give suprapubic
pressure
* raises legs of child
when occiput is against pubic
symphysis
• Piper forceps is used .
• Head is delivered slowly
(>1min.)to reduce compression

38. MAURICEAU SMELLIE-
VEIT TECHINIQUE
• BABY : Placed on supinated left hand with
limbs hanging .
• ASSISTANT : Give suprapubic pressure .
• LEFT HAND : Middle and index fingers are
placed on malar bones to maintain head
flexion.
• RIGHT HAND : Ring ,little finger on right
shoulder.
* index finger on left shoulder
.
* middle finger on
suboccipital region.
• Downward ,backward traction is given till
nape of neck is visible.

39. BREECH EXTRACTION
• IT is rarely done these days as it produce
trauma to the fetus and mother
THIRD STAGE = The third stage is usually
uneven full .
•The placenta is usually expelled out soon
after delivery of the head .
•If Ergometrine is to be given ,it should
be administered IV with crowning of the
head .

40. MANAGEMENT OF THIRD
STAGE
EXPECTANT MANAGEMENT ACTIVE MANAGEMENT
DELIVERY OF BABY
CLAMP,DIVIDE, LIGATE THE CORD
WAIT AND WATCH
PLACENTA SEPRATED THROGH
GRAVITY
ASSISTED EXPULSION OF
PLACENTA
INJECTION OXYTOCIN
10 UNITS IM
CLAMP ,DIVIDE ,LIGATE THE
CORD
DELIVERED PLACENTA BY
CONTROLLED TRACTION
WAIT FOR 10 MIN.,DELIVERD PLACENTA
MANUAL REMOVALMETHARGINE 0.2Mg IM
EXAMINE PLACENTA
INSPECT VULVA
,VAGINA,PERINEUM

41. FOURTH
STAGEIn the fourth stage perform strict supervision of both
mother and baby . In which restore health of the mother.
Prevent from infection .
• Emotional support
• Rest and ambulance
• Care of bowel and bladder
• Sleep
• Care of vulva, episiotomy wound * hospital stay
• Care of breast *maternal,infant
bonding
• Diet * Asepsis and

42. Special thanks for snehlata
mam