Call Girls Nagpur Just Call 9907093804 Top Class Call Girl Service Available
Breech presentation (2)
1. Case Presentation
on Breech Presentation
Presented by:
Saraswata Neupane
MN 2nd year (8th batch)
CMC, School of Nursing
2. Content of Case Presentation
Objectives of Case Study
Rational for selection of the Case
Bio-demographic data of my case
History taking and physical examination of
the case
4. Objective of the Case Study
General Objective:
To identify and synthesize the knowledge and
to provide comprehensive management care of
high risk case (Breech presentation)
5. Specific Objectives:
•To collect information regarding the bio -
demographic and present and past illness of
patient
•To apply knowledge from the basic science
nursing theories and other related course to
plan and implement nursing care of the
patient
•To gain thorough knowledge about high risk
case (Breech presentation) and its
management
6. Contd…
•To provide holistic nursing care to the client
using nursing process
•To find the patients need and problems
through the assessment and minimize help in
solving to reduce of patient’s illness and
hospitalization
7. Rationale for Selection of the Case
For gaining comprehensive knowledge about
this high risk pregnancy case, gaining
efficiency in its holistic management, provide
focused nursing care, prevent further
complication, provide support to patient and
family, I had chosen this case of Breech
presentation.
Besides, this case study also fulfils the partial
requirement of Master of Nursing curriculum
of Women Health and Development practicum.
8. Contd…
Incidence rate of Breech presentation occurs in
3% to 4% of all term pregnancies. A
higher percentage of breech presentations
occurs with less advanced gestational age. At
32 weeks, 7% of fetuses are breech, and 28
weeks or less, 25% are breech.
9. Contd…
Specifically, following one breech delivery, the
recurrence rate for the second pregnancy was nearly
10%, and for a subsequent third pregnancy, it was
27%.
In the USA, over 85% of all breech births are now by
caesarean section (up from 14% in 1970). Intrapartum
and neonatal deaths associated with breech
presentation appear to have been declining (pyane
and panthi, 2016)
11. Contd…
•Marital status : Married
•Religion : Hindu
•Address : Jutpani, Chitwan
•Source of income : Husband’s Service
•Husband occupation : Aboard
•Ward : Obstetric ward
12. Contd…
•IP no : 189767
•Diagnosis : G3PoLoA1 @ 37+2 WOG
with breech presentation
with pain abdomen
•Attending consultant : Dr. Raksha Joshi
•Date of admission : 2075/10/13
•Date of case taken : 2075/10/14
•Date of case ended : 2075/10/18
•Source of information : Patient herself
14. History of Present Illness
Patient was diagnosed case of breech
presentation and is in continuous follow-up in
Jutpani PHC. She was apparently well 3 days
back when she felt pain abdomen and
headache and She went to Chitwan Medical
College.
15. Menstrual and Obstetric History:
•Age at menarche : 13 years
•Duration of menses : 3-4days
•Menstrual cycle : 30 days cycle
•Intermenstrual Bleeding: Not present
•Post-coital bleeding : Not present
•Age at marriage : 18 yrs
•Last menstrual period : 2075/1/25
16. Obstetric History:
•Gravida : 3
•Para : 0
•Abortion : 2
before 1 year apart one and half month
and 2 month abortion was done
17. Present Pregnancy History
•Last Menstrual Period : 2075-1-25
•Expected date of Delivery : 2075-11-2
•Weeks of gestation :37+2 wks
•Had taken Ferrous sulphate and Calcium from
2nd trimester.
18. Contd…
•Two doses of Td vaccine taken
•Deworming in 2nd trimester
•Quickening at 20 weeks
20. Sexual and Contraceptive History
No any difficulties or pain in sexual
intercourse
Had used pills for 6 months.
21. Past Medical Surgical History
•Medical history: No any medical history
•Surgical history: She had no any history of any
surgeries.
•Drug allergy: She had no any significant
allergic history to any drugs.
•Hospitalization: No history of previous
hospitalization.
•Immunization taken: Not taken any
immunization
22. •Childhood illness: She had no any childhood
illness like Measles, Mumps, Chicken pox,
Rheumatic fever, Scarlet fever, Poliomyelitis
etc.
•Adulthood illness: She had no any other
adulthood illness like STDs (Sexually
Transmitted Diseases), Asthma, Hepatitis
(especially viral hepatitis), HIV infection
Contd…
23. Personal History
•Diet: Non vegetarian
•Sleeping pattern: good
•Bowel and Bladder: Normal
•Exercise: not specific apart daily activities
•Rest and sleep: She sleeps at least 8-9 hours
during pregnancy
24. Contd…
•No history of smoking and alcohol
•Allergies: No known history of allergies to
food, drugs or environment.
25. Family History
•No any history of chronic illness in her family
like hypertension, diabetes, cancer, blood
disease, tuberculosis etc
•No any history of congenital anomalies and
hereditary disease.
26. Physical Examination
Findings of physical examination
Physical examination was done on 14th Magh
2075 by applying cephalocaudal approach
Measurement
Height: 158 cm Weight: 56 kg
Body Tem. 98.6f Pulse: 80b/min
Blood pressure: 120/80 mm of hg
Respiration: 22 b/min
31. Contd…
Pelvic examination:
•No swelling or varicose vein of the external
genitalia
•Not any discharge
Per Vaginal (P/V) Examination
•Os: closed
•Effacement: not effacement
•Membrane: present
•Presenting part: High up
33. Introduction
It is the commonest malpresentation, the lie is
longitudinal, podalic pole present
in pelvic brim, presenting diameter is bitrochantric
(the distance between the outer point of the hips or
same) and the denominator is sacrum.
A breech birth is the birth of a baby from
breech presentation. In the breech presentation the
baby enters the birth canal with the buttock or feet
first as opposed to the normal head first
presentation
36. Incidence
The incidence is about 20% at 28th week and
drops to 5% at 34th week and to 3–4% at term.
Thus in 3 out of 4, spontaneous correction into
vertex presentation occurs by 34th week.
(Konar,2013)
37. Contd…
There were total 3160 deliveries during the
study period. Among them, 80 women had
breech presentation and hence the rate of
breech presentation was 2.53%. Caesarean
section was done in 38 (47.5%) women out of
which elective was done in 8 (10%) and
emergency in 30 (37.5%) cases.(Shrestha and
Shrestha , 2016)
38. Contd…
During given period there were 6153 deliveries. The
study consisted of 172 cases of breech delivery out of
them there were 106 term and preterm constituted 66
cases. Prevalence of breech delivery in this study was
2.79% Breech presentation was more common in
multipara having an incidence of 56.4%, while 43.6%
were primiparas. Vaginal delivery occurred in 52.90%
cases while caesarean section was done in 47.09%
cases. (paudel, et al., 2018 )
39. Contd…
There were 896 breech deliveries out of a total
44,842 deliveries giving an incidence of
1.99%. One hundred thirteen (12.61%) of
breech deliveries were through vaginal route
while 431 (48.10%) and 352 (39.28%) were
through emergency and elective caesarean
sections respectively. There were 154
(17.18%) preterm breech deliveries including
27 (17.5%) preterm intrauterine death. (Malla
et al., 2016)
40. Contd…
Women should be informed that when
planning delivery for a breech baby, the risk of
perinatal mortality is approximately 0.5/1000
with caesarean section after 39+0weeks of gestation;
and approximately 2.0/1000 with planned
vaginal breech birth. This compares to
approximately 1.0/1000 with planned
cephalic birth.(Mar 16, 2017 an international journal
obstretric and gyanocology)
41. Types
There are two types of breech presentation
•Complete
•Incomplete Complete (Flexed breech)
Complete : The normal attitude of full flexion is
maintained. Thighs are flexed at hips and legs at
knees. The presenting part consists of two buttocks,
external genitalia and two feet. It is commonly
present in multiparae (10%).
Incomplete: This is due to varying degrees of
extension of thighs or legs at the podalic pole. Three
varieties are possible:
42. Contd…
•Breech with extended legs (Frank breech):
In this condition, thighs are flexed on the trunk and
legs are extended at the knee joints. The presenting
part consists of the two buttocks and external
genitalia only. It is commonly present in
primigravidae, about 70%. The increased prevalence
in primigravida is due to a tight abdominal wall, good
uterine tone and early engagement of breech.
43.
44.
45. Contd…
•Footling presentation (25%): Both thighs and legs
are partially extended bringing the legs to present at
brim.
• Knee presentation: Thighs are extended but the
knees are flexed, bringing the knees down to present
at the brim. The latter two varieties are not common.
Clinical varieties: In an attempt to find out the
dangers inherent to breech, breech presentation is
clinically classified as:
46. Contd…
1) Uncomplicated—It is defined as one where there is
no other associated obstetric complications apart from
the breech, prematurity being excluded.
2) Complicated—When the presentation is associated
with conditions which adversely influence the
prognosis such as prematurity, twins, contracted
pelvis, placenta previa, etc. It is called complicated
breech. Extended legs, extended arms, cord prolapse
or difficulty encountered during breech delivery
should not be called complicated breech but are
called complicated or abnormal breech delivery.
47. Risk factors
•Lax uterus (usually associated with high maternal
parity).
•Uterine anomalies (eg, bicornuate or septate uterus)
or tumour.
•Placenta praevia.
•Abnormal pelvic brim.
•Fetal malformation (eg, hydrocephalus).
49. Etiology
•Prematurity: It is the most common cause of breech
presentation.
• Factors preventing spontaneous version:
(a) Breech with extended legs,
(b) Twins
(c) Oligohydramnios
(d) Congenital malformation of the uterus such as
septate or bicornuate uterus
(e) Short cord, relative or absolute
(f) Intrauterine death of the fetus.
50. Contd…
•Favorable adaptation:
(a) Hydrocephalus—big head can be well
accommodated in the wide fundus,
(b) Placenta previa,
(c) Contracted pelvis,
(d) Cornu-fundal attachment of the placenta—
minimizes the space of the fundus where the
smaller head can be placed comfortably.
51. Contd…
• Undue mobility of the fetus:
(a) Hydramnios,
(b) Multiparae with lax abdominal wall.
• Fetal abnormality: Trisomies 13, 18, 21,
anencephaly and myotonic dystrophy due to
alteration of fetal muscular tone and mobility.
54. Complete Breech Frank Breech
Per abdomen
fundal
palpation
Lateral
Palpation
Pelvic
palpation
FHS
Head—suggested by hard and
globular mass
Head is ballottable
Fetal back is to one side and the
irregular limbs to the other
Breech—suggested by soft, broad
and irregular mass
Breech is usually not engaged
during pregnancy
Usually located at a higher level
round about the umbilicus
Head
Irregular small parts of the feet
may be felt by the side of the
head
Head is non ballottable due to
splinting action of the legs on the
trunk
Irregular parts are less felt on the
side
Small, hard and a conical mass is
felt
The breech is usually engaged
Located at a lower level in the
midline due to early engagement
of the breech
55. Complete breech Frank Breech
Per vagina
during
pregnancy
during
labor
Soft and irregular
parts are felt through
the fornix
palpation of ischial
tuberosities, sacrum
and the feet by the
sides of the buttocks
The foot felt is identifi
ed by the prominence
of the heel and lesser
mobility of the great
toe
Hard feel of the
sacrum is felt, often
mistaken for the head
palpation of ischial
tuberosities, anal
opening and sacrum
only
56. Contd…
ULTRASONOGRAPHY is most informative.
(1)It confirms the clinical diagnosis—especially in
primigravidae with engaged frank breech or with tense
abdominal wall and irritable uterus.
(2) It can detect fetal congenital abnormality and also
congenital anomalies of the uterus.
(3) Type of breech (complete or incomplete).
(4) It measures biparietal diameter, gestational age and
estimated weight of the fetus.
(5) It also localizes the placenta.
(6) Assessment of liquor volume (important for ECV)
(7) Attitude of the head- flexion or hypertension
57. Contd…
POSITIONS:
Sacrum is the denominator of breech and there are
four positions. In anterior positions, sacrum is
directed toward iliopubic eminences and in posterior
positions, sacrum is directed to sacroiliac joints. The
positions are:
(1) First position—left sacroanterior (LSA)—being
the most common
(2) (2) Second position— right sacroanterior (RSA)
(3) Third position—right sacroposterior (RSP)
58. Diagnosis in my Patient
•CLINICAL
•ULTRASOUND
Single live fetus of 34-35 weeks of gestation with
breech presentation with single loop of cord adjacent
to the neck.
•OTHERS INVESTIGATIONS
Haemoglobin 12.7gm/dl pre LSCS,
11gm/dl post LSCS
RBS 107 mg/dl
Platetes count 191000/cumm
Urine RE/ME Normal
59. Management
Antenatal Management
Antenatal management in breech presentation
consists of:
• Identification of the complicating factors related
with breech presentation.
• External cephalic version, if not contraindicated.
•Formulation of the line of management, if the
version fails or is contraindicated.
60. Contd…
•Identification of complicating factor:
It can be detected by clinical examination,
supplemented by sonography. Sonography is
particularly useful to detect congenital
malformations of the fetus, the precise location
of the placental site and congenital anomalies
of the uterus.
61. Contd…
•External cephalic version
External version is a non-surgical method in which a
doctor can help move the baby within the uterus. A
medication to help relax the uterus might be given as
well as an ultrasound exam, to better check the
position of the baby, the location of the placenta, and
the amount of amniotic fluid in the uterus. Gentle
pushing on the lower abdomen can turn the baby into
the head-down position.
62. Contd…
Throughout the external version, the baby's
heartbeat will be checked closely so that if any
problems should occur, the health care
provider will stop turning immediately. Most
attempts at external version are successful;
however, as the due date gets closer this
procedure is more difficult.
64. Contd…
Contraindication of external cephalic version:
1.Antepartum haemorrhage (placenta previa or
abruption) _risk of placenta separation
2.fetal causes- congenital anomalies(major), dead
fetus, hyper extention of the head, fetal
compromise(IUGR)
3.Multiple pregnancy
4.Rupture membrane- with drainage of liquor
65. Contd…
5.Known congenital malformation of the
uterus
6.Contracted pelvis
7.Previous cesarean delivery – risk of scar
rupture.
8.Obstetric complication- severe pre-
eclampsia, obesity, elderly primigravida, bad
obstetric history
66. Contd…
•Management, if version fail or contraindicated: two
method of delivery can be planned
•To perform an elective cesarean section
•To allow spontaneous labour to start and vaginal
breech delivery to occur
Vaginal Breech delivery
Vaginal breech delivery is considered in cases with
adequate pelvis, average fetal weight (between1.5 and
3.5kg), flexed head and without any other
complication. Frank breech is preferred. In all such
cases one must ensure close monitoring of labour and
facilities for immediate cesarean delivery should
necessity arises
67. Management done in my patient
•Patient was admitted in maternity ward on 2075-
10-13
•All investigations were done and collected
•Vital sign taken an recorded.
•Monitor FHS regularly
•Medicine used
• Tab hyospan fort 20 mg TDS for 3 days
• Tab candid v6 1 tab PV x HS 3days
• INJ dexona 12 mg IM stat and after 12 hrly
•Plan for Elective Caesarion section
68. Prognosis
•Perinatal mortality is increased. Deaths are most
often associated with malformations, which are
more common in breech presentation, prematurity
and intrauterine fetal demise.
•Breech presentation is associated with an increased
risk of developmental dysplasia of the hip; an
ultrasound of the hips should be performed in all
babies who were breech at 36 weeks irrespective of
their presentation at delivery or the mode of
delivery.
69. Complications
•Premature rupture of membranes and premature labour.
•Cord prolapse (higher risk with footling or complete
breech).
•Fetal head entrapment.
•Overly rapid descent of after-coming head, leading to rapid
compression/decompression causing intracranial
haemorrhage.
•Cervical spine injuries associated with hyperextension.
•Delay in delivery, leading to asphyxia due to cord
compression and placental separation.
•Traumatic injuries including fractures of the humerus,
femur or clavicle, brachial plexus injury (Erb-Duchenne
palsy).
70. The Nursing Theory Application
Orem’s General Theory Of Nursing was applied while
providing holistic care to the patient.
The General Theory Of Nursing proposed by Orem is a
combination of three theories, i.e. theory of self care,
theory of self care deficit and the theory of nursing
systems.
The theory of Nursing system theory
•Nursing system theory refers to a series of action a nurse
takes to meet patients self care needs. It is determined by
the patients self care needs. It is composed of three
systems:
•Wholly compensatory
•Partially compensatory
•Supportive educative
71. Nursing Diagnosis
Acute pain related to the surgical wound
• Assess the level of pain
•Check the vital signs.
•Instructed the client to perform relaxation technique
such as deep breathing.
•Give medications as prescribed i.e inj ketrol 30mg
IV TDS.
72. Contd…
Anxiety & fear related to operative procedure as
evidenced by facial expression
•Encourage to ventilate her feeling and clear her
queries.
•Provide adequate information about disease
condition and procedure.
•Assess patient level of understanding and observe
the response.
•Establish calm and quiet environment.
73. Contd…
•Therapeutic relationship with patient &
family was developed.
•The patient was oriented to the hospital its
rules & facilities available.
•The patient was reassured that she is in safe
hands and not alone
•Assisted in anxiety reducing maneuvers:
relaxation, deep breathing and oral intake
of warm fluids
74. Contd…
Altered sleeping pattern related to new
environment and hospitalization as evidenced by
frequent awakening
•To assess the sleep and rest pattern.
•To provide quiet and peaceful environment.
•To encourage patient to sleep in regular time daily.
•Encourage patient to drink warm milk at bed time.
•To encourage the patient to talk and ventilate
her feeling at bedtime.
•To provide comfortable bedding and pillow.
75. Contd…
Risk for altered body fluid & electrolyte balance
related to loss of appetite
•Assess the fluid and electrolyte status.
•Monitor vitals, Intake/output.
•Monitor dryness of mucous membrane.
•Replace I/V fluid as needed.
•Provide oral fluids like water, black tea, soups etc
76. Contd…
Risk of developing hypoglycemia due to
ineffective breast feeding (for baby)
• breast feed the baby immediate after
delivery and every 2 hours or when baby
demands.
•Encourage mother to breastfeed the baby as
demanded by baby & teach her importance
of breast milk
77. Daily Progress Notes of the Patient
Admission Day (2075/10/13)
• Patient looks anxious
• Vital signs taken and recorded
• Blood investigations send.
• Her vital signs are:
- Temperature : 97.6°F
- Pulse : 82 beats/min
- B.P: 120/70 mm of Hg
- Respiration : 18b/ min
78. Contd…
2nd day of admission (2075/10/14)
•Patient was on observation
•History and physical examination was done
•Vital signs taken and recorded
•Her vital signs are:
- Temperature : 97.6°F
- Pulse : 82 beats/min
- B.P: 120/70 mm of Hg
- Respiration : 18b/ min
79. Contd…
OT day (2075/10/15)
• Patient was on NPO.
• Prepare the patient for OT
• vital signs was taken and recorded :
- Temperature: 98°F
- Pulse: 78 b/m
- Respiration: 20 b/m
- B.P: 110/80 mm of Hg
• Shifted the patient in OT
80. Contd…
• Patient shifted to postop ward.
•Patient was on NPO
• IV fluid was administered with inj oxytocin 10 unit
in
inj RL
• IV medication was continued
•Foleys catheter was present
• Monitors vitals regularly and recorded
• Intake /Output charting
81. Contd…
1st post-operative day (2075/10/16)
•Patient shifted to post natal ward
•Her general condition was well
•IV fluid was stop and foleys catheter was out
•Lochia rubra was present
•No any soakage from operative site, abdominal tenderness
• Breast no engorgement, Nipple inverted,
•Patient was on liquid diet,
•Vital sign was taken and recorded
• Pain management was done as prescribed
• Ambulation was done
82. Contd…
Baby was stable ,well feeding pattern normal
vital sign
Temperature: 98°F
Pulse: 144 b/m
Respiration: 44 b/m
83. Contd…
2nd post-operative day (2075/10/17)
• Patients looks fresh and well
• Vital sign was taken and recorded
• Oral medication was done
• Lochia rubra was present
• No any soakage from incision site
• Encourage patient to do breast feeding
• She was on liquid diet
• Ambulation was done
84. Contd…
3rd post-operative day (2075/10/18)
On discharge
• Patients looks fresh and well
• Vital sign was taken and recorded
• Oral medication was done
• Lochia rubra was present
• No any soakage from incision site
• Encourage patient to do breast feeding,
adequate milk secretion
• She was on soft diet, appetite normal no nausea
/vomiting
85. Discharge Teaching
She was discharged on 2075/10/18 with stable vitals
and improved clinically :
Medicines on Discharge
•Tab Pericef 200mg PO/BD for 3 days
• Tab flexon 1 tab PO/TDS for 3 days and than SOS
• Tab Aciloc 150mg PO/BD for 5 days
• Tab IFOL- XT 1 tab PO/OD for 45 days
86. Contd…
The following topics were covered during the
health teaching:
1.Nutrition for baby & mother
2.Breast care and breast feeding
3.Personal hygiene including pericare
4.Rest and resumption of activities
5.Care of the baby
88. Contd…
Nutrition:
Post-natal mothers require a balanced diet
to recuperate from the stress of parturition, meet the
caloric requirements of breast feeding and return to
normal daily activities. The diet of the
post natal mother should contain green
leafy vegetables, plenty of liquid, cereals, pulses and
meat. A post natal mother should take at least four
meals a day. Culturally influenced diet high on calorie
like ghee, Chakku, sweets etc are allowed.
This ensures that the baby acquires adequate calories
through the mother’s milk
89. Contd…
Breast care and Breast feeding:
Care of the breast commences from the ante-natal period.
I also raised the awareness of the
advantages of the breast feeding as opposed to commercia
l preparation. The mother is encouraged to feed the baby
soon after birth and demand of the baby.
The mother was taught the proper technique of breast feed
ing the baby. This includes the following:
•On demand feeds
•Proper positioning of the baby during feeds
•Burping the baby after feeds
90. Contd…
Rest and activities
The mother needs rest during the puerperium to
recuperate from the stress of labour and immediate
post natal period. The mother requires about 9
hours of sleep a day, and she needs about 45 days of
period to recover from pregnant state to non-pregnant
state after delivery. The mother is not allowed to
undertake heavy or labourious tasks during the
puerperium, as it predisposes to uterine prolapse.The
mother was taught about the pelvic floor exercises to
tone up the musculature
91. Contd…
Care of the baby:
The baby must be cleaned and cared daily. The
eyes, face and body must be wiped with a
clean cloth soaked with clean luke-warm
water. The umbilical cord stump must be
cleaned daily till it naturally drops off.The
baby’s diapers must be checked and changed
regularly. The perineum must be kept clean
and dry to prevent rashes
92. Contd…
Immunizations:
Active immunization against various bacterial
and viral childhood diseases is part of the
extended program for immunization in Nepal.
The parents had no good knowledge of the
immunization schedule.
93. Contd…
Weaning food:
The baby requires dietary supplement from 6
months of age as the baby grows and the
calories obtained from the breast milk becomes
inadequate. The parent’s knowledge of
weaning foods was reinforced when I
discussed the weaning techniques. They had a
good idea of home made preparations.
94. Contd…
Personal hygiene and pericare :
Good personal hygiene is a prerequisite for good
health. Encourage the mother to bathe and change
clothes daily. Pericare must be done after every
urination and defecation
The mother is educated about the types of lochia, its
odour and character. The mother was advised to
obtain consultation or any abnormality in lochia,
especially if she develops fever.
95. Contd…
Medicines:
My patient was prescribed antibiotics,
analgesics and she was further prescribed iron
and calcium supplements by the doctor. I
explained the justification for taking the
prescribed medications for the mentioned
durations.
96. Contd…
Follow up Visits:
The parents were advised to remove the suture
after one week from the date of operation.
The parents were advised to the baby’s first
immunization shot of BCG. They were further
advised to seek consultation in case of any
difficulty.
97. References
George , B.J,(2011). Nursing theories The basic for
professional nursing practice (6th Ed). Dorling
Kindersley India Pvt Ltd.
Gulanic, M., Klopp, A., Ealanes, S., Gradishar, D., &
Knoll P.M. Nursing Care Plans: Nursing Diagnosis
and Intervention. (3rd Ed.). Mosby.
Konar, Hiralal, (2015).DC Dutta’s Textbook of
Obstetrics. 8th edition. Jaypee.
Nettina, S. M. (2010). Lippincott Manual of Nursing
Practice. 9th Edition. New Delhi; Wolters Kluwer
(India) Pvt. Ltd.
