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Mellss obg y3 breech
- 1. Nur Amalina Aminuddin Baki 0820121000 67
- 2. Introduction Commonest malpresentation Longitudinal lie Podalic pole at pelvic brim
- 3. Incidence Incidence Gestational age 20% 28th 5% 34th 3-4% At term Lower in hospital where: External cephalic version is done Minimal high parity births
- 5. Complete breech • Flexed at hips and knees • Two buttocks, external genitalia and two feet • Common in multiparae (10%) Frank breech • Flexed at hips and extended at knees • Two buttocks, external genitalia • Common in primigravidae (70%) Footling presentation (25%) • Thighs and legs are partially extended • Legs Knee presentation • Etended thighs and flexed knees • Knees
- 6. Clinical varieties Uncomplicated No other associated obstetric complications Complicated When associated with conditions that adversely influence prognosis Prematurity, twins, contracted pelvis, placenta previa
- 7. Etiology Prematurity Factors preventing spontaneous version Breech with extended legs, twins, oligohydramnios, septate/ bicornuate uterus, short cord, IUFD Favourable adaptation Hydrocephalus, placenta previa, contracted pelvis, cornufundal placental attachment Undue mobility of fetus Hydramnios, multiparae with lax abdomen Fetal abnormalities Trisomies 13, 18, 21, anencephaly, myotonic dystrophy Recurrent/ habitual breech >3 recurrent breech presentation septate/ bicornuate uterus,cornufundal placental attachment
- 8. Diagnosis
- 9. Clinical Complete Breech Frank Breech Per abdomen Fundal grip • Ballotable head • Non-ballotable head (splinting action of legs) • Irregular parts of feet by side of head Lateral grip • Fetal back on one side • Irregular limbs on one side • Irregular parts are less felt Pelvic grip • Soft, broad,irregular mass • Not engaged during pregnancy • Small ,hard, conical mass • Usually engaged Fundal Height Shrinking • Located at higher level near umbilicus • Located at lower level in midline Per vaginam During pregnancy • Soft,irregular parts felt at fornix • Hard feel of sacrum felt During labor • Palpation of ischial tuberosities,sacrum and feet (prominence of heel and lesser mobility of great toe) • Palpation of ischial tuberosities, anal opening and sacrum only
- 10. Sonography Confirm clinical diagnosis Detect anomalies of fetus or uterus Type of breech Measures BPD, gestational age and approximate fetal weight Locate placenta Liquor volume assessment Attitude of head CT and MRI Assess pelvic capacity
- 11. Positions Denominator: sacrum Anterior: sacrum towards iliopubic eminence Posterior : sacrum towards sacroiliac joints Left sacro-anterior (LSA) Right sacro-anterior (RSA) Left sacro-posterior (LSP) Right sacro-posterior (RSP)
- 12. Mechanism of Labor Principal movements at Buttocks Shoulders Head Buttocks and shoulders are bigger but more compressible Head is non-moulding ( rapid descent)
- 13. Buttocks Shoulders Head Diameter of engagement: oblique diameter Engaging diameter: bi- trochanteric (10cm) Bi- sacromial (12cm) Sub occipitofrontal (10cm) Descent of buttocks till anterior buttocks touches the pelvic floor Descent of shoulders Descent with increasing flexion Internal rotation of 1/8th of a circle Further descent till anterior hip hinges under the pubic symphysis Internal rotation of 1/8th of a circle External rotation 1/8th of a circle of buttocks Internal rotation of occiput 1/8th or 2/8th of a circle Further descent till subocciput hinges under the pubic symphysis Delivery of anterior and posterior hips and lower limbs Delivery of posterior and anterior shoulder Head is born by flexion: chin, mouth, nose, forehead,vertex and occiput Restitution Restitution causing anterior shoulder towards right thigh (LSA) / left thigh (RSA) External rotation of shoulder Due to internal rotation of
- 15. Sacro- posterior Similar mechanism with sacro-anterior Internal rotation of head is 3/8th of a circle occiput behind pubic symphysis
- 16. Prognosis Maternal Increased operative delivery increased genital tract trauma,sepsis, anesthetic complications Increased morbidity Fetal Perinatal mortality 9-25% Perinatal death 3-5 times higher Fetal mortality least in frank breech and maximum in footling presentation Factor influencing fetal risk: Skill of obstetrician Weight of baby Leg’s position Type of pelvis
- 17. Fetal dangers Intrapartum fetal death Intracranial hemorrhage Birth asphyxia Birth injuries Hematoma - sternomastoid/ thighs Fracture – femur, humerus, clavicle, odontoid process Visceral injuries- liver/ kidney / lungs rupture Nerve – Erb’s / Klumpke’s palsy Long-term neurological damage Prevention of fetal hazards Minimize breech incidence by ECV Delivery by cesarean section Vaginal breech delivery by skilled obstetrician, anesthesist, neonatologist
- 18. Management
- 19. Antenatal management Identify complicating factors related with breech External cephalic version, if not contraindicated Formulation of line of management,if ECV failed
- 21. External Cephalic Version Done to bring favourable cephalic pole in the lower pole of uterus Success rate 60% > 36 weeks Late version is difficult but Less chance of reversion Effective management of any fetal complications Use of tocolytic reduces difficulties
- 22. Contraindications Antepartum hemorrhage Fetal : hyperextended head, > 3.5 kg, dead fetus, IUGR Multiple pregnancy Malformations of uterus Abnormal CTG Previous cesarean delivery Obstetric complications: severe pre-eclampsia, obesity, elderly primigravida, BOH Rhesus isoimmunization
- 23. Successful version likely in : Complete breech Non-engaged breech Sacro-anterior position Adequate liquor Non-obese patient Failed version likely in: Frank breech Scanty liquor/ big baby Mechanical- obesity, irritable uterus Short cord Uterine malformations
- 24. Advantages Reduce breech incidence at term Reduce breech delivery incidence Reduce cesarean delivery Dangers Premature labor PROM Placental separation Cord entanglement Feto-maternal bleeding Amniotic fluid embolism
- 25. Procedures Administration of tocolytic ( terbutaline 0.25mcg SC/ Isoxsuprine 50-100 µg IV) USG – confirm diagnosis and adequate liquor A reactive NST Empty bladder Position of patient: supine with shoulders slightly raised, thighs slightly flexed and abdomen fully exposed Fetal presentation, position of back and limbs are checked FHR auscultated
- 26. ‘Forward Roll’ Movement Step 1 Mobilize breech using both hands towards which back of fetus lie Right hand : grasp podalic pole Left hand: grasp head
- 27. Step 2 L:Pressure exerted to head to push breech R:Pressure in opposite direction to guide vertex Intermittent pressure given till lie become transverse FHR is checked
- 28. Step 3 Changing of hands Intermittent pressure exerted till head is brought to lower pole of uterus
- 29. Reactive NST should be obtained Undue bradycardia ( head compression) is settled down by 10 minutes If persist, cord entanglement may occur and reversion is done. Patient is observed for 30 minutes to : Allow FHR to settle down Note any vaginal bleeding/ sign of PROM Patient is advised for follow-up, to report any vaginal bleeding/leakage and Rh-negative woman is given 100µg anti-D IG IM.
- 30. If ECV / contraindicated Continue with usual check-up Assessment is done based on Maternal age Associated complicating factors Size of baby Pelvic capacity Clinical assessment of pelvis is done Eg.CT/MRI/ USG To plan the method of delivery
- 31. Elective Cesarean Section 15-50% >3.5 kg baby Stargazing fetus Footling presentation Contracted pelvis Severe IUGR Vaginal Breech Delivery Average fetal weight Flexed fetal head Adequate pelvis No other complications Availability of: Emergency LSCS facilities Continuous labor monitoring facilities Experienced obstetrician
- 32. Management of Vaginal Breech Delivery
- 33. First Stage: Vaginal examination At onset of labor for pelvic adequacy Soon after membrane rupture for cord prolapse IV line with Ringer’s solution, avoid oral intake and send blood for group and cross-matching Adequate analgesia is given Fetal status and progression of labor are monitored Oxytocin infusion for augmentation of labor Indication for CS: Arrest of labor Non-reassuring FHR pattern Cord presentation/prolapse
- 34. Second stage Spontaneous (10%): not preferred Assisted breech : by assistance from beginning to the end Breech extraction : part/entire body of fetus is extracted by obstetrician Indications: delivery of 2nd twin after IPV Cord prolapse Extended legs
- 36. The following are to be kept ready beforehand: Anesthetist Assistant Instrument and suture for episiotomy A pair of obstetric forceps Appliances to resuscitate baby Neonatologist Principles in conduction : Never to rush Never to pull from below but push from above Always keep fetal back anteriorly
- 37. Steps Woman in lithotomy position is tilted laterally(15%) using a wedge uder the back to avoid aortocaval compression Bladder is emptied and antiseptic cleaning is done Pudendal block with perineal infiltration/ epidural analgesia is done Episiotomy: To straighten birth canal To facilitate intravaginal manipulation and forceps delivery To minimize head compression Patient is encouraged to bear down as it ensure flexion of head and safe descent
- 38. Delivery of trunk ‘NO TOUCH’ policy till buttocks and legs are delivered and the trunk slips up to umbilicus After the trunk up to the umbilicus is born: The extended legs are delivered by abduction at knees Umbilical cord is pulled down and mobilized to one side to minimize compression If back remain posterior, rotate the trunk anteriorly The baby is wrapped in sterile towel To prevent slipping when held To facilitate manipulation
- 39. Delivery of the arms Assistant apply pressure on fundus to prevent extension of arms Position of arm is noted If flexed, vertebral border of scapula is parallel to vertebral column If extended, there is winging of scapula Arm is delivered when one axilla is visible by hooking down elbow with a finger Baby should be held by feet over the sterile towel during delivery of arm
- 40. Delivery of Head Time gap between delivery of umbilicus and mouth: 5 – 10 minutes Methods: a) Burns- Marshall method b) Forceps delivery c) Modified Mauriceau- Smellie- Veit technique
- 41. a)Burns- Marshall method Baby: allowed to hang by its weight Assistant: downward, backward suprapubic pressure to promote head flexion Right hand: grasp ankles 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 head Left hand: guard the perineum
- 42. b)Forceps delivery Baby: allow to hang 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 (>1 min) to reduce compression-decompression
- 43. c)Modified Mauriceau- Smellie- Veit technique Aka malar flexion and shoulder traction 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 and little fingers on right shoulder Index finger on left shoulder Middle finger on sub-occipital region Downward, backward traction is given till nape of neck is visible Upward, forward traction to release face and brow Depressed to release occiput and vertex
- 44. Resuscitation of baby if asphyxiated 3rd stage: uneventful Preterm breech ECV not recommended CS done when fetal weight < 1.5kg
- 46. Arrest of buttocks 1. At Outlet Causes Outlet contraction Big baby and extended legs Weak uterine contraction Rigid perineum Contracted pelvis/ big baby – CS In absence of contracted pelvis/ big baby: Episiotomy, fundal pressure with groin traction Groin traction Index finger is placed in groin fold and traction is given towards trunk till delivery of the knee
- 47. 2. In the Cavity ( at/ above ischial spine) Causes Contracted pelvis Big baby Weak uterine contraction Trial of breech – when cervix fully dilated,breech should descent down to perineum If fail, CS- best treatment Pinard’s Maoeuvre- frank breech Pinard’s Manoeuvre Middle and index fingers are carried up to popliteal fossa, then exert pressure and leg is abducted Fetal foot is grasped at ankle and pulled down
- 48. Arrest of shoulders Cause: extended arm with lateral/dorsal (nuchal) displacement due to faulty technique Diagnosis: By observing winging of scapula Absence of flexed limbs in front of chest Management: Lovset’s maneuver Classical ( intrauterine manipulation under GA) Left hand:introduced along sacral curve( baby pulled slightly upwards), posterior arm is pushed over fetal head Right hand:introduced along sacral curve( baby’s trunk is depressed), anterior arm is delivered from anterior aspect Nuchal displacement of arm Flexed at elbow, extended at shoulder Trunk is rotated 180 towards fingers of trapped arm draw elbow forward Lovset’s Maneuvre
- 49. Lovset’s Maneuvre Advantages: Wider applicability No intrauterine manipulation Effective for all arm displacement No general anesthesia needed Principle: When anterior shoulder is above pubic symphysis, posterior shoulder is below sacral promontory. When posterior shoulder is rotated forward, it will appear below pubic symphysis. Baby grasped using both hands by femoro- pelvic grip Start only when inferior angle of anterior scapula is visible under pubic arch 1. Baby lifted slightly and rotated 180 with downward traction, then hooked out 2. Trunk rotated in reverse and anterior arm is hooked out.
- 50. Arrest of head At the brim Causes: deflexed head, contracted pelvis, hydrocephalus malar flexion with shoulder traction with suprapubic pressure (only in deflexed head) or craniotomy ( contracted pelvis, hydrocephalus) In the cavity Causes: deflexed head,contracted pelvis Delivery by forceps or malar flexion with shoulder traction (only in deflexed head) At the outlet: Causes: rigid perineum, deflexed head Episiotomy with forceps/ malar flexion and shoulder traction
- 51. Delivery of head through incompletely dilated cervix Causes: premature baby, footling presentation, hasty breech delivery Management: Shoe-horn method- cervix is pulled up while trunk traction is made by malar flexion and shoulder traction Duhrssen’s incision at 2,6 and 10 o’clock position on cervix Perforation of head (dead baby)
- 52. Occipito-posterior head Usually in spontaneous breech delivery Grasp fetal trunk and head with hands positioned like that in malar flexion and shoulder traction, then rotate to bring them anteriorly In premature baby, (Prague Maneuver)- head is delivered face to pubis by reverse malar flexion and shoulder traction Forceps
- 53. Conclusion External Cephalic Version Management Assisted breech delivery Buttocks: knee abduction Shoulders: hooking down elbow Head: Burns-Marshall method, Forceps delivery, Malar flexion and shoulder traction Complicated breech delivery Buttocks: groin traction, Pinard’s Maneuver Shoulders: Classical, Lovset’s Maneuver Head:Malar flexion and shoulder traction, Shoe- horn method, Duhrssen’s method, Prague Method
- 54. Reference
Editor's Notes
- Any difficulties in breech delivery ( extended arms, cord prolapse) = complicated breech delivery
- ICH- comp and decomp of non moulding head tear in tentorium cerebelli n hemorrhage in subarchnoid space. More in preterm Asphyxia – cord compression, retraction of placenta, premature attempt of respiraton, delayed head delivery, cord prolapse
- Rush n pull trapping of head in incompletely dilated cervix, traction causes deflection of head posing longer ocipitofrontal diameter at inlet
- Assistnt: to help intro of blades frm below. Too much elevation= head extension Piper= no pelvic curve