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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
Thank you for attentionThank you for attention