Presented by:
Ahmad mukhtar
MD.,M.B.B.Ch., M.Sc Obstetrics and GynecologyConsultant and Lecturer of Obstetrics and Gynecology, Faculty of
MEDICINE, Zagazig University.
Presented by:
Ahmad mukhtar
MD.,M.B.B.Ch., M.Sc Obstetrics and GynecologyConsultant and Lecturer of Obstetrics and Gynecology, Faculty of
MEDICINE, Zagazig University.
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
For more notes: Join Us on Telegram: https://t.me/OBGYN_Note_Book Or Facebook: https://www.facebook.com/obgyn.books
Slideshare: https://www.slideshare.net/bjlomsecond
“Difficulty encountered in the delivery of the fetal shoulders after delivery of the head.”
Shoulder dystocia is an unpredictable obstetric complication with the incidence of 0.15% to 2%.
An increase in the incidence of shoulder dystocia has been recorded over the last 20 years. Incidence appears to be increasing as birth weights increase.
For more notes: Join Us on Telegram: https://t.me/OBGYN_Note_Book Or Facebook: https://www.facebook.com/obgyn.books
Slideshare: https://www.slideshare.net/bjlomsecond
This presentation was prepared by me, Dr. P. Chizororo, to help fellow professionals understand one of the most common malpresentations, Breech presentation. Visit my YouTube channel, Nexus Medical Media for all pre-clinical subjects
BREECH PRESENTATION obstetrics and gynacology mbbs final yearsarath267362
BREECH PRESENTATION obstetrics and gynacology mbbs final year
presentation , pregnancy
final year mbbs
normal labor
breech labor complications
management
BREECH
tdmc kerala
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
2. INTRODUCTION
In breech presentation, the lie is longitudinal and the podalic pole presents at the pelvic brim.
It is the most common malpresentation.
Incidence: is about 20% at 28th week and drops to 5% at 34th week and to 3–4% at term.
4. COMPLETE (FLEXED BREECH):
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%).
5. INCOMPLETE BREECH
This is due to varying degrees of extension of thighs or legs at the podalic pole.
Three varieties are possible:
6. A) 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.
7. B) FOOTLING PRESENTATION
Both thighs and legs are partially extended
bringing the legs to
Incidence is about (25%)
Ususally present at brim.
8. C) 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.
9. CLINICAL VARIETIES:
In an attempt to find out the dangers inherent to
breech, breech presentation is
clinically classified as:
(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.
10. ETIOLOGY OF BREECH PRESENTATION
There is higher incidence of breech in earlier weeks of pregnancy.
Smaller size of the fetus and comparatively larger volume of amniotic fluid allow the fetus to undergo
spontaneous version by kicking movements until by 36th week when the position becomes stabilized.
11. FACTORS RESPONSIBLE FOR BREECH PRESENTATION.
The following are the known In a significant number of cases, the cause remains obscure.
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.
12. Favorable adaptation:
(a) Hydrocephalus—big head can be well accommodated in the wide fundus,
(b) (b) Placenta previa,
(c) (c) Contracted pelvis,
(d) (d) Cornu-fundal attachment of the placenta— minimizes the space of the fundus where the smaller head can be placed
comfortably.
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.
Recurrent breech:
On occasion, the breech presentation recurs in successive pregnancies.
When it recurs in three or more consecutive pregnancies, it is called habitual or recurrent breech.
15. 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 eg: (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 hyperextension (important for decision making at the time of
delivery).
16. POSITIONS: OF THE BREECH PRESENTATION
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) Second position— right sacroanterior (RSA)
(3) Third position—right sacroposterior (RSP) and
(4) Fourth position—left sacroposterior (LSP).
17. MECHANISM OF LABOR IN BREECH
PRESENTATION
SACROANTERIOR POSITION:
In the mechanism of breech delivery,
the principal movements occur at three places—buttocks, shoulders and the head.
The first two successive parts to be born are bigger but more compressible while the head because of
non molding due to rapid descent, presents difficulties.
Each of the three components undergo cardinal movements as those of normal mechanism.
18. 1) BUTTOCKS
1. the diameter of engagement of the buttock is one of the oblique diameters of the inlet.
2. the engaging diameter is bitrochanteric (10 cm or 4") with the sacrum directed toward the iliopubic
eminence.
When the diameter passes through the pelvic brim, the breech is engaged.
3. Descent of the buttocks occurs until the anterior buttock touches the pelvic ! oor.
4. Internal rotation of the anterior buttock occurs through 1/8th of a circle placing it behind the symphysis
pubis.
19. 5. Further descent with lateral flexion of the trunk occurs until the anterior hip hinges under the symphysis
pubis which is released first followed by the posterior hip.
6. Delivery of the trunk and the lower limbs follow.
7. Restitution occurs so that the buttocks occupy the original position as during engagement in oblique
diameter.
20.
21. II. SHOULDERS
Bisacromial diameter (12 cm or 4 3/4") engages in the same oblique diameter as that occupied by the
buttocks at the brim soon after the delivery of the breech.
Descent occurs with internal rotation of the shoulders bringing the shoulders to lie in the anteroposterior
diameter of the pelvic outlet.
the trunk simultaneously rotates externally through 1/8th of a circle.
Delivery of the posterior shoulder followed by the anterior one is completed by anterior flexion of the
delivered trunk.
Restitution and external rotation: Untwisting of the trunk occurs putting the anterior shoulder toward
the right thigh in LSA and left thigh in RSA.
External rotation of the shoulders occurs to the same direction because of internal rotation of the occiput through 1/8th of a
circle anteriorly.
the fetal trunk is now positioned as dorso anterior.
22. III. HEAD
Engagement occurs either through the opposite oblique diameter as that occupied by the buttocks or
through the transverse diameter.
the engaging diameter of the head is suboccipitofrontal (10 cm).
Descent with increasing flexion occurs.
Internal rotation of the occiput occurs anteriorly, through 1/8th or 2/8th of a circle placing the occiput
behind the symphysis pubis.
Further descent occurs until the subocciput hinges under the symphysis pubis.
Head is born by flexion—chin, mouth, nose, forehead, vertex and occiput appearing successively. "
expulsion of the head from the pelvic cavity depends entirely upon the bearing-down efforts and not at all
on uterine contractions.
23. Sacroposterior position:
In sacroposterior position, the mechanism is not substantially modified.
The head has to rotate through 3/8th of a circle to bring the occiput behind the symphysis pubis.
24. PROGNOSIS OF VAGINAL BREECH DELIVERY
MATERNAL:
Labor is usually not prolonged.
But because of increased frequency of operative delivery including cesarean section, the morbidity is increased.
The risks include
trauma to the genital tract,
operative vaginal delivery (episiotomy, forceps),
cesarean section,
sepsis and
anesthetic complications.
As a consequence, maternal morbidity is slightly raised.
Frank breech acts as an effective cervical dilator.
Flexed breech, although, theoretically might cause delay in first stage, but rarely so because of its prevalence among
multiparae.
25. FETAL:!The fetal risk in terms of perinatal mortality is considerable in vaginal breech delivery.
It is difficult to assess the magnitude of the real risk because the complicating factors, such as
prematurity,
birth trauma, congenital malformation of the fetus that contribute significantly to the fetal hazards.
The corrected (excluding fetal abnormality) perinatal mortality ranges from 5 to 35 per 1,000 births.
The overall perinatal mortality in breech still remains 9–25% compared with 1–2% for nonbreech
deliveries.
Perinatal death (excluding congenital abnormalities) is 3 to 5 times higher than the nonbreech
presentations.
26. THE FACTORS WHICH SIGNIFICANTLY INFLUENCE THE FETAL RISK ARE—
(a) skill of the obstetrician,
(b) weight of the baby,
(c) position of the legs and
(d) type of pelvis.
The fetal mortality is least in frank breech and maximum in footling presentation, where the chance of
cord prolapse is also more.
Gynecoid and anthropoid pelvis are favorable for the aftercoming head.
The fetal risk in multipara is no less than that of primigravida.
This is because of increased chance of cord prolapse associated with flexed breech.
27. THE DANGERS TO THE BABY
(1) Intrapartum fetal death specially with preterm babies
(2) Injury to brain and skull —
(a) Intracranial hemorrhage: Compression followed by decom pression during delivery of the
unmolded after-coming head results in tear of the tentorium cerebelli and hemorrhage in the
subarachnoid space. The risk is more with preterm babies,
(b) Minute hemorrhages,
(c) Fracture of the skull.
28. (3) Birth asphyxia: It is due to—
(1) Cord compression soon after the buttocks are delivered and also when the head enters into the pelvis.
A period of more than 10 minutes will produce asphyxia of varying degrees.
(2) Retraction of the placental site,
(3) Premature attempt at respiration (amniotic fluid, vaginal fluid) while the head is still inside,
(4) Delayed delivery of the head,
(5) Cord prolapse and
(6) Prolonged labor.
29. (4) Birth Injuries (7%): The following injuries are inflicted during manipulative deliveries.
It is 13 times more than the vertex presentation.
Hematoma—over the sternomastoid or over the thighs.
Fractures—The common sites are femur, humerus, clavicle and odontoid process. there may be dislocation
of the hip joint, mandible or 5th and 6th cervical vertebrae and epiphyseal separation.
Visceral injuries include rupture of the liver, kidneys, suprarenal glands, lungs and hemorrhage in the
testicles.
Nerve—Medullary coning, spinal cord injury, stretching of the cervical and brachial plexus to cause either
Erb’s or Klumpke’s palsy .
Long-term neurological damage.
30. 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.
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.
31. EXTERNAL CEPHALIC VERSION (ECV):
There are protagonists and antagonists to external version.
. The success rate of version is about 65%
Successful version reduces the risk of cesarean section significantly.
Prior sonography should be a routine.
Cardiotocography (CTG) should ideally be done before and after the procedure
32. TIME OF VERSION:
ECV has been considered from 36 weeks onward.
While version in the early weeks is easy but chance of reversion is more.
Late version may be difficult because of increasing size of the fetus and diminishing volume of liquor
amnii.
the use of uterine relaxant (tocolysis) has made the version at later weeks less difficult.
It minimizes chance of reversion and should fetal complications develop, it can be effectively tackled by
cesarean section.
33. BENEFITS OF ECV
(i) Reduction in the incidence of breech presentation at term,
ii) Reduction in the incidence of breech delivery (Vaginal or cesarean) and the associated complications
(iii) Reduction in the incidence of cesarean delivery by 5%.
34. Successful version is likely in cases of:
(i) Complete breech,
(ii) Nonengaged breech,
(iii) Sacroanterior position (fetal back anteriorly),
(iv) Adequate liquor,
(v) Nonobese patient.
35. DANGERS OF VERSION:
The dangers of version are—
(1) premature onset of labor,
(2) premature rupture of the membranes,
(3) placental abruption and bleeding,
(4) entanglement of the cord round the fetal part or formation of a true knot leading to impairment of fetal
circulation and fetal death and
(5) increased chance of fetomaternal bleed.
(6) Amniotic fluid embolism.
Immunoprophylaxis with anti-D gammaglobulin is to be administered in nonimmunized Rh-negative mother .
The perinatal mortality should not exceed beyond 1%. A reactive cardiotocographic trace should be obtained
after the procedure (see p. 693).
36. DELIVERY PLAN
Two methods of delivery can be planned.
1. To perform an elective cesarean section.
2. To allow spontaneous labor to start and vaginal breech delivery to occur.
37. ELECTIVE CESAREAN SECTION:
Because of the complications involved in vaginal breech delivery, there is a tendency to liberalize the use
of cesarean section in breech.
The indications of CS in breech are:
Big baby (estimated fetal weight >3.5 kg),
small baby (<1.5 kg), estimated fetal weight <1.5 or >3.5 kg,
hyperextension of the head (stargazing fetus), footling presentation (risk of cord prolapse),
suspected pelvic contraction or severe IUGR.
Anyassociated complications (obstetric or medical) is often considered for CS in breech.
38. The overall incidence of cesarean section in breech ranges from 15% to 50%, out of which about 80% is
elective.
Delivery of preterm breech (weight <1,500 g) by cesarean section is commonly done but it should be
reserved in selected centers, equipped with intensive neonatal care unit.
41. THE SCORE USED PARITY, GESTATIONAL AGE, ESTIMATED WEIGHT, PRIOR
SUCCESSFUL BREECH VAGINAL DELIVERY, DILATION, AND STATION TO
ASCERTAIN LIKELIHOOD OF SUCCESSFUL VAGINAL DELIVERY
42. A Zatuchni-Andros score of less than 4 accurately predicted poor outcomes in patients with infants
presenting as a breech.
43. FIRST STAGE:
The management protocol is similar to that mentioned in normal labor.
The following are the important considerations.
Spontaneous onset of labor increases the chance of successful vaginal delivery.
Vaginal examination is indicated—
(a) at the onset of labor for pelvic assessment,
(b) soon after rupture of the membranes to exclude cord prolapse.
An intravenous line is sited with Ringer’s solution, oral intake is avoided, blood is sent for group and cross
matching (considering the chance of CS).
Adequate analgesia is given, epidural is preferred.
Fetal status and progress of labor are monitored.
Oxytocin infusion may be used for augmentation of labor
44. Indications of Cesarean Section (CS):
(a) Cases seen for the first time in labor with presence of complications;
(b) Arrest in the progress of labor;
(c) Non reassuring FHR pattern (Fetal distress);
(d) Cord presentation or prolapse.
45. SECOND STAGE:
There are three methods of vaginal breech delivery:
Spontaneous (10%): Expulsion of the fetus occurs with very little assistance.
Assisted breech: the delivery of the fetus is by assistance from the beginning to the end.
this method should be employed in all cases.
Breech extraction (partial or total): When part or the entire body of the fetus is extracted by the obstetrician. It
is rarely done these days as it produces trauma to the fetus and the mother.
Indications are:
(a) Delivery of the second twin after IPV
(b) Cord prolapse,
(c) Extended legs arrested at the cavity or at the outlet.
46. ASSISTED BREECH DELIVERY
Breech delivery should be conducted by a skilled obstetrician.
The following are to be kept ready beforehand, in addition to those required for conduction of normal
labor:
(1)Anesthetist—to administer anesthesia as and when required.
(2) An assistant—to push down the fundus during contraction.
(3)Instruments and suture materials for episiotomy.
(4) A pair of obstetric forceps for the aftercoming head, if required.
(5) Appliances for resuscitation of the baby, if asphyxiated.
(6) Neonatologist.
47. PRINCIPLES IN CONDUCTION:
(1) Never to rush,
(2) Never pull from below but push from above
(3) Always keep the fetus with the back
anteriorly.
It is expected that good uterine contractions and
maternal expulsive forces will maintain the
flexion of the fetal head and result in descent
and safe delivery.
48. STEPS:
patient is brought to the table when the anterior buttock and fetal anus are visible.
She is placed in lithotomy position when the posterior buttock distends the perineum.
To avoid aortocaval compression, the woman is tilted laterally (15°) using a wedge under the back.
Antiseptic cleaning is done, bladder is emptied with an “in and out” catheter.
Pudendal block is done along with perineal infiltration if not epidural has been used earlier.
Episiotomy: It should be made in all cases of primigravidae and selected multiparae.
Its advantages are—
(a) to straighten the birth canal which especially facilitates the delivery of breech with extended legs where lateral flexion is
inadequate;
(b) to facilitate intravaginal manipulation and for forceps delivery,
(c) to minimize compression of the aftercoming head.
49. the best time for episiotomy is when the perineum is distended and thinned by the breech as it is
“climbing” the perineum.
The patient is encouraged to bear down as the expulsive forces from above ensure flexion of the fetal head
and safe descent.
the “no touch to the fetus” policy is adopted until the buttocks are delivered along with the legs in flexed
breech and the trunk slips up to the umbilicus.
Soon after the trunk up to the umbilicus is born. the following are to be done:
50. the e extended legs (in frank breech) are to be decomposed by pressure on the knees (popliteal fossa) in
a manner of abduction and flexion of the thighs.
51. If the umbilical cord is to be pulled down and
to be mobilized to one side of the sacral bay to
minimize compression.
there may be transient abnormality in cord
pulsation at this stage which has got no
prognostic significance.
An attempt of hasty delivery for this reason
alone should be avoided.
(c) If the back remains posteriorly, rotate the trunk
to bring the back anteriorly (SACROANTERIOR).
(d) the baby is wrapped with a sterile towel to
prevent slipping when held by the hands and to
facilitate manipulation, if required.
52. DELIVERY OF THE ARMS:
The assistant is to place a hand over the fundus and keep a steady pressure during uterine contractions
to prevent extension of the arms.
Soon, the anterior scapula is visible. The position of the arm should be noted.
When the arms are flexed, the vertebral border of the scapula remains parallel to the vertebral
column and when extended there is winging of the scapula (parallelism is lost).
The arms are delivered one after the other only when one axilla is visible, by simply hooking down each
elbow with a finger.
It is immaterial as to which arm is to be delivered first.
The baby should be held by the feet over the sterile towel while the arms are delivered
53.
54. DELIVERY OF THE AFTERCOMING HEAD:
This is the most crucial stage of the delivery.
The time between the delivery of umbilicus to delivery of mouth
should preferably be 5–10 minutes.
There are various methods of delivery for the aftercoming head.
Each one is quite safe and effective in the hands of an expert,
conversant with that particular technique
55. THE FOLLOWING ARE THE COMMON METHODS EMPLOYED:
(a) Burns-Marshall method
(b) Forceps delivery:
(c) Malar flexion and shoulder traction (modified Mauriceau-
Smellie-Veit technique):
56. (A) BURNS-MARSHALL METHOD
The baby is allowed to hang by its own weight.
The assistant is asked to give suprapubic pressure with the flat of hand in a downward and backward
direction, the pressure is to be exerted more toward the sinciput.
The aim is to promote flexion of the head so that favorable diameter is presented to the pelvic cavity.
Not more than 1–2 minutes are required to achieve the objective.
When the nape of the neck is visible under the pubic arch, the baby is grasped by the ankles with a
finger in between the two.
Maintaining a steady traction and forming a wide arc of a circle, the trunk is swung in upward and
forward direction (Fig. 26.18).
Meanwhile, with the left hand to guard the perineum, slipping the perineum off successively the face and
brow.
When the mouth is cleared off the vulva, there should be no hurry. Mucus of the mouth and pharynx is
cleared by mucus sucker.
The trunk is depressed to deliver rest of the head.
57.
58. (B) FORCEPS DELIVERY:
Forceps can be used as a routine.
The head must be in the cavity.
The advantages of foreps delvery: —
(a) delivery can be controlled by giving pull directly on the head and the force is not transmitted through
the neck,
(b) flexion is better maintained and
(c) mucus can be sucked out from the mouth more effectively.
The head should be brought as low down as possible by allowing the baby to hang by its own weight aided
by suprapubic pressure.
59. When the occiput lies against the back of the symphysis pubis, an assistant raises the legs of the child as
much to facilitate introduction of the blades from below.
Too much elevation of the trunk may cause extension of the head.
The forceps pull maintains an arc, which follows the axis of the birth canal (Fig. 26.19).
Piper forceps is especially designed (absent pelvic curve) for use in this condition.
The head should be delivered slowly (over 1 minute) to reduce compression-decompression forces
that may cause intracranial bleeding.
60.
61. (C) MALAR FLEXION AND SHOULDER TRACTION (MODIFIED
MAURICEAU-SMELLIE-VEIT TECHNIQUE):
The technique is named after the three great obstetricians who described the use of the grip
independently.
The baby is placed on the supinated left forearm (preferred) with the limbs hanging on either sides.
The middle and the index fingers of the left hand are placed over the malar bones on either sides
(modification of the original method, where the index finger was introduced inside the mouth).
This maintains flexion of the head.
The ring and little fingers of the pronated right hand 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.
62.
63. The assistant gives suprapubic pressure during the period to maintain flexion.
Thereafter, the fetus is carried in upward and forward direction toward the mother’s abdomen releasing
the face, brow and lastly, the trunk is depressed to release the occiput and vertex.
Resuscitation of the baby: The baby may be asphyxiated and need to be resuscitated.
64. THIRD STAGE:
The third stage is usually uneventful.
The placenta is usually expelled out soon after delivery of the head.
If prophylactic ergometrine is to be given, it should be administered intravenously with the crowning of
the head.
65. MANAGEMENT OF COMPLICATED BREECH DELIVERY
DELAY IN DESCENT OF THE BREECH:
The breech may be arrested: •
At the outlet • at the cavity • At the brim
• Arrested at the outlet:
The causes are—
(a) big size baby with extended legs (the most common),
(b) (b) weak uterine contractions,
(c) (c) rigid perineum and
(d) (d) outlet contraction.
Management: If the outlet is contracted and/or the baby is big, cesarean section even at this stage, is the method
of choice
66. In the absence of outlet contraction and feto-pelvic
disproportion:
Liberal episiotomy and fundal pressure with or
without groin traction (either single groin or
both the groins) usually become effective (Fig.
26.21).
The index finger(s) is placed in the groin fold and
traction (along with uterine contraction) is
exerted more toward the trunk than toward the
femur (risk of fracture femur).
67. FRANK BREECH EXTRACTION
(Pinard’s maneuver)— is done by intrauterine
manipulation (for breech decomposition) to
convert a frank breech to a footling breech.
This is possible when the membranes have
ruptured recently.
In Pinard’s maneuver, the middle and the index
fingers are carried up to the popliteal fossa.
It is then pressed and abducted so that the fetal
leg is flexed.
The fetal foot is then grasped at the ankle and
breech extraction is accomplished.
68. LOVSET’S MANEUVER: The maneuver should start
only when the inferior angle of the anterior scapula
is visible underneath the pubic arch.
It is widely practiced in preference to the classical
method of bringing down an arm.
The following are the advantages:
(1) Wider applicability—It can be applied even
when the classical method becomes difficult.
(2) Intrauterine manipulation is nil.
(3) A single manipulation is effective to all types of
displacement of the arms.
(4) General anesthesia is usually not needed.
69. Step—1: 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.
Step—2: The trunk is then rotated in the reverse
direction keeping the back anterior to deliver the
erstwhile anterior shoulder under the symphysis
pubis.
Nuchal displacement of arm is where the arm is
flexed at the elbow and extended at the
shoulder and lies behind the fetal head.
After grasping the baby at the pelvic girdle with
thumbs along the sacrum, the trunk is rotated
180° toward the fingertips of the trapped arm.
This may draw the elbow forward and render it
amenable to Lovsett’s maneuver.
If this fails, the arm is forcibly extracted by
hooking. In that case fracture almost always
follows.
70. ARREST OF THE AFTERCOMING HEAD
• At the brim:
The causes of arrest are—
(1) deflexed head
(2) contracted pelvis and
(3) hydrocephalus.
Management:
(1) If the arrest is due to a deflexed head, the
delivery is to be completed by malar flexion and
shoulder traction along with suprapubic pressure
by the assistant.
The head is to be negotiated through the brim in
the transverse diameter and rotated in the cavity.
Forceps should not be applied in high head.
(2) If the arrest of the head is due to contracted
pelvis or hydrocephalus, perforation of head is
to be don
71. In the cavity:
The causes of arrest of the head in the cavity
are—(1) deflexed head and (2) contracted pelvis.
The best management
is delivery of the head by forceps which is
effective in both the circumstances.
Malar flexion and shoulder traction may be
effective only in deflexed head.
72. • At the outlet:
The causes of arrest are—
(1) rigid perineum and
(2) deflexed head.
Episiotomy followed by forceps application or
malar flexion and shoulder traction is quite
effective.
73. DELIVERY OF THE HEAD THROUGH AN INCOMPLETELY DILATED
CERVIX:
The common causes are—
(1) premature baby,
(2) macerated baby,
(3) footling presentation and
(4) hasty delivery of breech before the cervix is fully dilated.
Management:
If the baby is living, the cervix is to be pushed up while traction of the fetal trunk is made by malar flexion and
shoulder traction (shoe-horn method).
If necessary, Duhrssen’s incision can be made at 2 and 10 O’ clock position on the cervix.
If the baby is dead, perforation of the head is better than watchful expectancy, hoping for full dilatation of the
cervix.