BREECH PRESENTATION BREECH PRESENTATION & &

DELIVERYDELIVERY

PanwadPanwad RattanasrithongRattanasrithong INT2INT2

Definition & Clinical Definition & Clinical importanceimportance

DefinitionDefinition

The presentation that the fetus is in The presentation that the fetus is in longitudinal lie and its buttock enter the longitudinal lie and its buttock enter the pelvis firstpelvis first

IncidenceIncidence

33--4% of singleton deliveries4% of singleton deliveries15% at 29 15% at 29 –– 32 weeks32 weeks

ETIOLOGYETIOLOGYPrecipitating factorPrecipitating factor

Gestational ageGestational ageGreat parity / Multiple fetuses (uterine Great parity / Multiple fetuses (uterine relaxation)relaxation)HydramniosHydramnios / / OligohydramniosOligohydramniosHydrocephalus / Hydrocephalus / AnencephalusAnencephalusPrevious breech deliveryPrevious breech deliveryUterine anomalies / Pelvic tumorsUterine anomalies / Pelvic tumorsPlacenta Placenta previaprevia

Types of breechTypes of breech

Types of breech Types of breech Frank breechFrank breech : flexed at hips and : flexed at hips and extended at kneesextended at kneesComplete breechComplete breech : flexed at hips and : flexed at hips and flexed at kneesflexed at kneesIncomplete breechIncomplete breech : one or both hips : one or both hips are not flex and one or both feet or knees are not flex and one or both feet or knees lie below the breechlie below the breech

DiagnosisDiagnosis

AbdominalAbdominal examinationexamination

11stst Leopold maneuver: ballottementLeopold maneuver: ballottement

22ndnd Leopold maneuver: large partLeopold maneuver: large part33rdrd Leopold maneuver: movableLeopold maneuver: movable44thth Leopold maneuver:Leopold maneuver: prominenceprominence

Vaginal ExaminationVaginal Examination

Palpable : both Palpable : both ischialischial tuberosities,thetuberosities,thesacrum and the anus sacrum and the anus DDxDDx : Face presentation (Mouth and : Face presentation (Mouth and MalarMalar eminence)eminence)Position & Variety : Position & Variety : Sacrum&SpinusSacrum&Spinusprocessprocess

Imaging TechniquesImaging Techniques

UltrasoundUltrasoundCTCTMRIMRI

Mechanism of deliveryMechanism of delivery

Mechanism of deliveryMechanism of delivery

Denominator Denominator

Mechanism of deliveryMechanism of delivery

Engagement Engagement Descent Descent Internal rotationInternal rotationLateral flexionLateral flexionExternal rotationExternal rotationBirth : breech Birth : breech body body headhead

Mechanism of deliveryMechanism of delivery

Engagement

Descent

Mechanism of deliveryMechanism of delivery

Internal rotation Lateral flexion

Mechanism of deliveryMechanism of delivery

External rotation Birth : breech

Mechanism of deliveryMechanism of delivery

Birth : body head

Modes of deliveryModes of delivery

Modes of deliveryModes of delivery

Cesarean sectionCesarean sectionVaginal deliveryVaginal delivery

Spontaneous breech deliverySpontaneous breech deliveryAssisted breech deliveryAssisted breech delivery(Partial extraction)(Partial extraction)Total breech extractionTotal breech extraction

Vaginal deliveryVaginal delivery

Vaginal deliveryVaginal deliveryEntrapment of fetal head : Entrapment of fetal head : DuhrssenDuhrssen

incision incision Entrapment of fetal arm behind the neck Entrapment of fetal arm behind the neck

((nuchalnuchal arm)arm)ProlapseProlapse cord : complete cord : complete –– 5% ,footling5% ,footling--

15%15%

DuhrssenDuhrssenincision incision

Vaginal deliveryVaginal deliveryUnfavorable pelvisUnfavorable pelvis

GynecoidGynecoid & anthropoid : favorable& anthropoid : favorablePlatypelloidPlatypelloid & Android : unfavorable & Android : unfavorable

Vaginal deliveryVaginal delivery

Hyperextension Hyperextension 5 % in term breech presentation5 % in term breech presentationResult : Injury to C spinal cordResult : Injury to C spinal cordMarked hyperextension : C/SMarked hyperextension : C/S

Vaginal deliveryVaginal delivery

Labor induction & AugmentationLabor induction & AugmentationNo significant mortality and No significant mortality and ApgarApgar

between infant with induced between infant with induced vsvs spontanousspontanous]]OxytocinOxytocinAmniotomyAmniotomyCT confirm adequate pelvisCT confirm adequate pelvis

Vaginal deliveryVaginal deliveryManagement of laborManagement of labor

Establish : Establish : Membranes,labor,FetalMembranes,labor,Fetalcondition,UCcondition,UC

Notified nurseryNotified nurseryStage of Labor : Stage of Labor : CxCx , , EffEff , Station ,Presentation , Station ,Presentation Fetal Monitoring : Fetal Monitoring :

FHR q 15 min (most continue EFM)FHR q 15 min (most continue EFM)PV check cord PV check cord prolapseprolapse & FHR q 5& FHR q 5--10min (MR)10min (MR)

Vaginal deliveryVaginal delivery

Methods of Vaginal deliveryMethods of Vaginal deliverySpontaneous breech deliverySpontaneous breech deliveryPartial breech extractionPartial breech extractionTotal breech extraction Total breech extraction

Vaginal deliveryVaginal delivery

Assisted Breech DeliveryAssisted Breech Delivery

Vaginal deliveryVaginal delivery

The posterior hip of frank breech is delivering

Vaginal deliveryVaginal delivery

The anterior hip has now delivered and external rotation has occurred. The fetal thighs remain in flexion with extension knees.

Mode of Mode of deliverydelivery

Delivery of theDelivery of thelegslegs by placing by placing the fingers the fingers parallel with parallel with medial aspect of medial aspect of the femur and the femur and displacing displacing laterally and away laterally and away from midlinefrom midline

Mode of Mode of deliverydelivery

Delivery of the body.Delivery of the body.

Delivery of the shoulderDelivery of the shoulder

Cats paw methodCats paw methodClassical methodClassical methodLovsetLovset ‘‘s methods method

Cats paw methodCats paw method

Cats paw methodCats paw method

Classical Classical MethodMethod

LovsetLovset’’ss MethodMethod

Partial breech extraction or Partial breech extraction or breech assistingbreech assisting

Delivery of the Delivery of the aftercomingaftercoming headheadMauriceauMauriceau--SmellieSmellie--veitveit maneuvermaneuverPrague maneuverPrague maneuverPiper forcepsPiper forceps

MauriceauMauriceau--SmellieSmellie--VeitVeit ManeuverManeuver

Prague maneuverPrague maneuver

The back of the The back of the fetus fail to fetus fail to rotate to the rotate to the anterioranterior

Piper ForcepsPiper Forceps

Total breech extractionTotal breech extraction

IndicationIndication1. Prolong second stage of labor1. Prolong second stage of labor2. Twin2. Twin3. Maternal disease3. Maternal disease4. 4. ProlapseProlapse cordcord5. Fetal distress5. Fetal distress

Total breech extractionTotal breech extraction

ContraindicationContraindication1. Cervix not fully dilated1. Cervix not fully dilated2. CPD2. CPD

Total breech extractionTotal breech extraction

The hand is introduced through the vagina The hand is introduced through the vagina &both feet of the fetus are grasped&both feet of the fetus are graspedGentle traction the feet through the vulvaGentle traction the feet through the vulvaBreech appears at the vulva, gentle Breech appears at the vulva, gentle traction until the hips are deliveredtraction until the hips are deliveredassisted breech delivery assisted breech delivery

Complete Complete breech breech extraction extraction begins with begins with traction on the traction on the feet and anklesfeet and ankles..

continues with continues with traction on the traction on the thighsthighs

the scapulas the scapulas becomes becomes visible and the visible and the body rotates, body rotates, usually to the usually to the side of the side of the mother mother

Cesarean sectionCesarean section

RecommendationRecommendationLarge fetusLarge fetusContraction or unfavorable shape of pelvisContraction or unfavorable shape of pelvisHyperextendedHyperextended headheadDelivery is indicated but not in laborDelivery is indicated but not in laborUterine dysfunctionUterine dysfunctionIncomplete or footling presentationIncomplete or footling presentation

Cesarean sectionCesarean section

RecommendationRecommendationHealthy preterm Healthy preterm Severe fetal growth restrictionSevere fetal growth restrictionPrevious Previous perinatalperinatal death or newborn death or newborn complication of birth traumacomplication of birth traumaA request for sterilizationA request for sterilizationLack of an experienced operatorLack of an experienced operator

Morbidity & MortalityMorbidity & Mortality

Maternal InjuriesMaternal InjuriesRisk : Operative interventionRisk : Operative interventionManipulations : Risk infectionManipulations : Risk infectionIntrauterine maneuvers : Rupture of the Intrauterine maneuvers : Rupture of the

uterus +/uterus +/-- lacerations of lacerations of CxCxExtensions of the episiotomy Extensions of the episiotomy Uterine Uterine atonyatony , Postpartum hemorrhage, Postpartum hemorrhage

Morbidity & MortalityMorbidity & MortalityPerinatalPerinatal Morbidity & MortalityMorbidity & Mortality

Preterm delivery & low birth weight & IUGRPreterm delivery & low birth weight & IUGRProlapseProlapse cordcordBirth Birth aphyxiaaphyxiaFetal InjuriesFetal Injuries

FxFx of of humeroushumerous and clavicleand clavicleFxFx of femurof femurHematomasHematomas of of sternocleidomastoidsternocleidomastoidSeparation of epiphyses of Separation of epiphyses of scapular,humerusscapular,humerus or femuror femurBrachial plexusBrachial plexusAvulsion of upper CAvulsion of upper C--spinespineSkull Skull FxFx , , intracerebralintracerebral injuryinjury

IntracerebralIntracerebral haemorrhagehaemorrhage

Birth asphyxiaBirth asphyxia

VersionVersion

VersionVersion

External cephalic versionExternal cephalic versionInternal Internal podalicpodalic versionversion

External Cephalic VersionExternal Cephalic Version

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