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Breech presentation

and Delivery
Tanitra Tantitamit
22 May 2007
Breech presentation
The incidence is highly dependent on the gestational age.
At 20 weeks‘ about ¼ preganacies, By full term, the incidence is about 4%.
Etiology
Etiology
Factors that appear to predisposes to breech presentation
ƒ Hydramnios
ƒ Uterine relaxation associate with great parity
ƒ Multiple fetus
ƒ Hydrocephalus
ƒ Anencephaly
ƒ Previous breech delivery
ƒ Uterine abnormalities
ƒ Pelvic tumor
ƒ Placenta implantation at cornual-fundal region
Complications
Complications

• Perinatal morbidity and mortality from difficult delivery


• LBW from preterm delivery, IUGR or both
• Prolapsed cord
• Placenta previa
• Fetal,neonatal and infant anomalies
• Uterine anomalies and tumor
Diagnosis
Diagnosis

•Complete Breech •Incomplete breech •Frank Breech


5%-10% 25%-30% 60%-65%
Diagnosis

• Abdominal examination
– Hard round and ballotable fetal head is found to
occupy the fundus
– The breech is movable in pelvic inlet
(no engagement) or beneath pelvic symphysis
(engagement)
– FHS heard loudest above the umbilicus
Diagnosis

• Vaginal examination
– Frank breech
• Both ischial tuberrosities sacrum and anus are palpable
• The mouth and malar eminence form triangular shape
whereas the ischial tuberosities and anus are in straight line
– Complete breech
• Feet may be felt alongside the buttock
– Incomplete breech
• One or both feet are inferior to the buttock
Diagnosis

• Imaging technique
– Ultrasound
• Confirm a clinically suspected
breech presentation and
fetal anomalies
• If vaginal delivery is considered
– Type of breech presentation
– Degree of flexion or deflexion of head
Diagnosis

• Imaging technique
– CT scan
• Provide pelvic measurement and configuration
at lowest dose of radiation
– MRI
• Provide reliable pelvic capacity and architecture without
ionizing radiation but not available
– X-RAY
• Varies among study, there was no correlation between pelvic
measurement and labor outcome
Prognosis
Prognosis
• Maternal morbidity
– Because of the higher risk of cesarean delivery,there is higher
maternal morbidity and slightly higher mortality

• Perinatal morbidity and mortality


– The major contributors to perinatal loss are preterm delivery,
congenital anomalies and birth trauma
Vaginal delivery
Vaginal delivery
• With a term fetus,
– head molding may be essential for it to negotiate the birth canal
successfully
– In certain case
• Delivery may be delayed while the aftercoming head
accommodate pelvis, resulting in hypoxia and acidemia
• Delivery may be forced , causing trauma from compression,
traction or both
– The overall neonate morbidity and mortality resulting from trauma
were increase significant in planned vaginal delivery group
Vaginal delivery
• With a preterm fetus,
– Disparity between size of head and buttock cause hypoxia
and physical trauma
– 6% Nucral arm
– Prolapse cord
(Cephalic 0.4% , Frank 0.5%, Complete breech 5% and in footling 15%)
– Short umbilical cord and multiple coils of cord entangling the
fetus are more common
develop nonreassuring fetal heart pattern and low apgar score at 1min
– Preterm infant undergoing cesarean section had better prognosis
Vaginal delivery
• Unfavorable cervix
– Because there is no time to molding head,
contract pelvis might prove dangerous
• Unfavorable : Platypelliod (AP flat) Android (Heart shape)
• Favorable : Gynecoid (round) Antroploid( Elliptical)

• Hyperextension
– Present in 5% of breech presentation, result in injury
of cervical spinal cord and considered an indication
of cesarean section
Vaginal delivery
• Labor induction and augmentation
– Defended by some clinicians and condemned by others

• Footling breech
– Possibility of compression of a prolapsed cord or cord entangled
around the extremities is threat fetus
Vaginal delivery
• Recommendation for cesarean delivery
– A large fetus
– Any degree of contraction or unfavorable shape of pelvis
– Hyperextended head
– When delivery is indicated in the absence spontaneous labor
(some clinician used oxytocin)
– Uterine dysfunction (some clinician used oxytocin)
Vaginal delivery
• Recommendation for cesarean delivery
– Footling breech
– Healthy ,viable preterm fetus with mother in active labor
– Severe IUGR
– Previous perinatal death
– Request for sterilization
– Lack of an experienced operator
Technique for breech delivery
Mechanism of labor
• Engagement and descend of breech
– Bitrochanteric diameter
in oblique pelvic diameter
• Internal rotation 45° of breech
– Bitrochanteric diameter
in anteroposterior pelvic diameter
• Lateral flexion of body
– Forced by perineal floor
• External rotation of breech
and internal rotation of shoulder
– Biacromian and bitrochanteric in AP diameter
• Flexion of head upon the thorax then rotates in a such manner as
to bring the posterior of neck under pubic symphysis
Methods of vaginal delivery
• Spontaneous breech delivery
– Without traction or manipulation other than support infant
• Partial breech extraction
– Delivered spontaneously as far as the umbilicus.
– Body is extracted with operator traction and assisted maneuver
• Total breech extraction
– The entire body of the infant is extracted by the obstetrician
Management of labor
• Rapid assessment the status of labor
– Satisfactory progress in labor was the best indicator of pelvic adequacy
– Close surveillance FHR and UC

• Assessment fetal condition


– USG to detect anomalies and extended head if vaginal delivery is planned
– Monitoring FHS every 15min ,prefer continue EFM
– When MR, PV to check for cord prolapse ,
special attention should be directed to FHR for first 5-10 min

• Immediate recruitment of nursing ,obstretrical


and anesthesia team
Frank breech delivery
• Spontaneous delivery
• Assisted frank breech delivery
– Delivery of aftercoming head
– Entrapment of the aftercoming head
• Frank breech extraction
Spontaneous vaginal delivery
The anterior buttock appears at the introitus
A mediolateral episiotomy
Further descent of the anterior buttock
Both buttocks come into view
as well as the anterior thigh.

The buttocks are expelled


by voluntary maternal effort.

The fetal sacrum rotates anteriorly.


Spontaneous vaginal delivery
The legs are delivered by flexion
of the thighs and knees.

delivery of the anterior shoulder

delivery of the posterior shoulder.

The trunk is allowed to hang


to encourage descent of the head.
Assisted vaginal breech delivery
No downward or outward traction is
applied until the umbilicus has been
reached

A towel wrapped around the fetal hips,


gentle downward and outward traction
in conjunction with maternal expulsive
efforts until the scapula is reached

Don’t elevate body and keep the body low


Assisted vaginal breech delivery
After the scapula is reached,
ƒThe fetus should be rotated 90°
in order to deliver the anterior arm
ƒThe anterior arm is followed to the elbow,
and the arm is swept out of the vagina.
ƒThe fetus is rotated 180°,
and the contralateral arm is delivered.
ƒThe infant is then rotated 90°
to the backup position in preparation for delivery of the head.
ƒThe fetal head is maintained in a flexed position
by using the Mauriceau maneuver
Delivery of the aftercoming head
• Mauriceau maneuver
– Index and middle finger of one
hand are applied over maxilla to
flex the head
– Use the other hand to grasp the
baby’s shoulders.
– Downward traction until
suboccipital region appear PS
– Elevate body toward maternal
abdomen
Delivery of the aftercoming head
• Prague maneuver
– Rarely ,the back of the fetus on posterior

Prague maneuver
Consists of two fingers of one
hand grasping the shoulders
of the back-down fetus from
below while the other hand
draws the feet up over
maternal abdomen
Delivery of the aftercoming head

• Forceps to aftercoming head


– Piper or Divergent Laufe
• Suspension of body in a
towel effectively holds
the fetus and help keep
the arm out the way
Piper forcep for delivery head
Entrapment of aftercoming head
DÜhrssen incision
DÜhrssen incision
Incision at 10 o’clock , 2 o’clock
and may required at 6 o’clock

IV nitroglycerin
Not compelling evidence

Zavanelli maneuver
C/S after replacement of infant into uterus

Symphysiotomy
rare use, serious maternal injury
Frank breech extraction
Moderate traction exerted by finger in
each groin and facilitated by generous
episiotomy

Pinard maneuver
Two fingers are inserted along one extremity to
the knee , then pushed away from midline after
spontaneous flexion to deliver a foot into vagina
Morbidity and Mortality
Maternal injuries
Increase risk of infection
caused by manual manipulation within birth canal
Rupture of uterus and cervical laceration
Intrauterine maneuver ,delivery of aftercoming head
through an incompletely dilate cervix
Deep perineal tear
Extension of episiotomy
Fetal injuries
Fracture humerous and clavicle
Fracture femur
Hematoma of sternocliedomastoid muscle,
usually disappear spontaneously
Brachial plexus injuries (Paralyse arm)
Thank you