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- 2. Learning Objectives At theend of the class, the student will be able to •Define breech Presentation •Classify the types of Breech •Enlist the causes of Breech •Enumerate the examination techniques •Discuss the management of Breech •Demonstrate on mechanism of labour •Describe the types of assisted breech delivery
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- 4. Definition Breech presentation iswhen the lie of the baby is longitudinal and pelvic or podalic pole of foetus presents at the brim and cephalic pole at the fundus
- 5. INCIDENCE • The nearestpart of the fetus to the pelvic brim is the buttocks and lower limbs • The denominator in case of breech is the sacrum • Depends on the gestational age of the fetus • Before term between 28 –36 weeks 10-15 % • After 37 completed weeks 3%
- 6. TYPES • all jointsare flexed the feet presents beside the buttocks. Complete breech (flexed breech) • One or both legs extended at the hip, so that the foot is the presenting part. Incomplete breech (extended breech) • extended knee joints with flexion of the hip Frank Breech
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- 8. Etiology Prematurity fetal abnormality multiple pregnancy Polyhydramnios Oligohydramnios placentapraevia uterine abnormality pelvic masses multipart y
- 9. Factors preventing spontaneousversion Breech with extended legs Twins Oligohydramn ios Congenital malformation Short cord IUD
- 10. Symptoms Pain under theribs Discomfort Indigestio n Hard mass at the hypochondrium Fetal movements in the lower abdomen
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- 15. Antenatal Management Insure fetal wellbeing Searchfor causes of breech presentation Possibility of change to cephalic ECV Mode of delivery
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- 17. Management during labour Typeof Delivery Vaginal Spontaneous Partial Breech Extraction Total Breech Extractio n LSCS
- 18. Breech allowed todeliver vaginally •No other indications for CS •No other complication medical or obstetrical with breech •Estimated fetal size between 2.5 to 3.5 kg •Adequate pelvis
- 19. In labor Proper History Reviewof AN record/ Investigations Partograph/ continuous fetal monitoring IV fluids/ Fasting Inform Neonatologist Informed consent
- 20. Management of Labor-Mother Start IV access for anesthesia/resuscitation. PV to assess cervical dilatation, effacement & station of the presenting part. Satisfactory progress in labor is the best indicator of pelvic adequacy.
- 21. Management of Labor-Fetus Fetal heart rate recorded at least every 15 minutes. If a nonreassuring, decision must be made regarding the necessity of cesarean delivery.
- 22. MECHANISM of BREECH Characteristics- -Longitudinal - Breech - Left sacro anterior - Complete flexion - Sacrum •Lie •Presentation •Position •Attitude •Denominator •Presenting part - Anterior part of the Left buttocks
- 23. Restitution takes placebuttocks turns to the mother’s right side Anterior buttocks escapes under symphysis pubis and posterior buttocks sweeps the perineum. Buttocks is born by the movement of flexion Buttocks is the leading part which reaches the pelvic floor and rotates 1/8th of circle anteriorly and lies under the symphysis pubis. Bitrochanteric diameter is now anteroposterior diameter of the outlet Descent takes place with increased compaction of the body and increased flexion of the limbs. Sacrum is facing right iliopectineal eminence and the extremities are facing left sacro iliac joint. Engaging diameter is bitrochanteric diameter 10cm
- 24. Chin, face andsinciput sweeps the perineum head is born by the movement of flexion. Simultaneously external rotation of the body takes place and back becomes the uppermost part. Head enters the pelvis and sagital suture lies in the transverse diameter of the brim.internal rotation of the head takes place and head impinges behind the symphysis pubis Shoulder enters the pelvis with left oblique diameter and anterior shoulder rotates 1/8th of the circle anteriorly comes under symphysis pubis, anterior shoulder escapes under symphysis pubis and posterior shoulder sweeps the perineum
- 25. ASSISTED BREECH • Breechdelivery should be conducted by a skilled obstetrician. The following are to be kept ready before hand, in addition to those required for conduction of normal labour; • Anaesthetist • An assistant to push down the fundus during contraction • Instruments and suture materials for episiotomy • A pair of obstetric forceps for aftercoming head, if required • Appliances for revival of the baby, if asphyxiated. Principles in conduction • Never to rush • Never pull from below, but push from above • Always keep the fetus with back anteriorly.
- 26. Assisted Breech Techniques AfterComing Head Burns Marshall Mauriceau Smillie Veit Technique Pipers Forcep s Extended Arms Lovset Manueve r Extended Legs Pinard’s Manuever
- 28. Malar flexion andshoulder traction (Modified MauriceauSmellie-Veit Technique):
- 29. Malar flexion andshoulder traction (Modified MauriceauSmellie-Veit Technique): •The middle and the index fingers of the left hand are placed over the malar bones on either sides . this maintains the flexion of the head. •The ring and little fingers of the pronated right arm are placed on the child’s right shoulder, the index finger is placed on the left shoulder and the middle finger is placed on the suboccipital region. • Traction is now given in downward and backward direction till the nape of the neck is visible under the pubic arch.
- 30. Forceps delivery- PipersForceps
- 31. Forceps delivery- PipersForceps • Suspension of the body of the fetus in a towel effectively holds the fetus up and helps keep the arms and cord out of the way as the forceps blades are applied. • Piper forceps have a downward arch in the shank to accommodate the fetal body and lack a pelvic curve • Once in place, the blades are articulated, and the fetal body rests across the shanks. • The head is delivered by pulling gently outward and raising the handle simultaneously
- 32. Extended Arms- LovsetManeuver • The baby is lifted slightly to cause lateral flexion. The trunk is rotated through 180˚ keeping the back anterior and maintaining a downward traction. This will bring the posterior arm to emerge under the pubic arch which is then hooked out. • The trunk is then rotated in the reverse direction keeping the back anterior to deliver the rest while anterior shoulder under the symphysis pubis
- 33. Frank Breech Extraction(Pinard’s maneuver)
- 34. Frank Breech Extraction(Pinard’s maneuver) • The hand, the palmar surface of which corresponds with the ventral aspect of the fetus is to be introduced to disimpact the buttocks so that the anterior buttock can be pushed up atleast to the level of the symphysis pubis. • The middle and the index fingers are to follow the thigh, preferably the anterior until the popliteal fossa is reached. With the fingers, the popliteal fossa is pressed and abducted so that the leg becomes partially flexed. Simultaneously, with the external hand the head is pressed down so that the footling drops down when it can be caught at the ankles by the internal fingers. The leg is pulled down by a movement of abduction. • The other leg is similarly brought down and the delivery is completed by breech extraction.
- 35. C-Section Indication o Alarge fetus ( > 3.500 gr ) o A Hyperextended fetus o Uterine dysfunction o Footling presentation o Any degree of contraction or unfavorable shape restriction o Previous perinatal death or children suffering from birth trauma
- 37. Complications- Maternal Discomfort and sub costalpain Dyspepsia Prolonged labor M. Distress Increased manipulation and m. trauma Puerperal sepsis High incidence of C/S rate
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- 39. Nursing management •Anxiety relatedto concern about possible cesarean section •Risk for fetal distress related to increased risk of prolapsed cord •Risk for alteration in labour progress related to abnormal fetal presentation •Risk for fetal injury related to operative delivery •Risk for ineffective coping related to situational Crisis •Risk for Maternal Infection related to operative delivery
- 40. Nursing Interventions • Followingthe diagnosis of persistent breech presentation, women should be assessed for risk factors for a poorer outcome in planned vaginal breech birth. • Intrapartum management • Fetal monitoring • Position of the woman • The optimal maternal position for birth is upright • Pain relief • Epidural analgesia may increase the risk of intervention with a vaginal breech birth. • All obstetricians and midwives should be familiar with the techniques that can be used to assist vaginal breech birth. The choice of manoeuvres used, if required to assist with delivery of the breech, should depend on the individual experience/preference of the attending doctor or midwife.
- 41. Knowledge Deficit relatedto Information misinterpretation
- 42. Fluid Volume Deficitrelated to restricted fluid intake
- 43. Risk for fetalinjury related to cord prolapse
- 44. CONCLUSION •The incidence ofBreech presentation expected to be low in hospitals where high parity births are minimal and routine external cephalic version done in antenatal period. •Breech presentation can be managed by early diagnosis and effective management strategies. By using different maneuvers and skillful observation of the obstetrician.
- 45. REFERENCE • Annamma Jacob’s.(2004).AComprehensive textbook of Midwifery. Jaypee Brothers and Publishers:New Delhi. • D. C. Dutta’s.(2004).Textbook of Obstetrics.New Central Book Agency: Calcutta. • Emily slone McKinney.(2009).Maternal – Child Nursing.Saunders Elsevier: Missouri.
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