preterm breech
TRANSCRIPT
-
7/28/2019 Preterm Breech
1/38
CORRECTION
References
Breech delivery in ALARM ( Advance Labour And Risk Management ) Internatio
PIT HOGSI 2013
-
7/28/2019 Preterm Breech
2/38
PRETERM BREEC
DELIVERY
VAGINAL DELIVERY VS. CAESAREAN SE
-
7/28/2019 Preterm Breech
3/38
Breech the buttocks of the fetusenter the pelvis before the head
The incidence of breech earlypregnancy 40% at 20 weeks, 25%at 32 weeks, and only 3-4% by term
Preterm birth < 37 completedweeks of pregnancy
Preterm breech perinatal
mortality 2 to 4 fold the mode of
delivery
Fetalmalformations,
prematurity, andintrauterine fetal
death commoncauses of
perinatal mortality.
(Hannah et al)obstetricianspreterm breech
delivery as a high-risk situation, dealtwith by primary CS
risk of surgery tothe mother from CSdelivery of an early
preterm breechfetus include the
need for a verticaluterine incision,
risk ofhaemorrhage,
bladder injury, anduterine tears.
There are also risks in subsequent
pregnancies :uterine rupture,
placenta previa andplacenta acreta.
-
7/28/2019 Preterm Breech
4/38
IDENTITY
Name : Mrs. SD
Age : 32 years old
MR No. : 82 64 59
Date : April 27th 2013
Chief Complain:
A 32 years old patient was aDelivery Room of Dr. M. DjamGeneral Hospital on April 27pm referred by midwife with
preterm pregnancy + Breech
-
7/28/2019 Preterm Breech
5/38
Present Illness History
Feeling of pain from waist region which referred to the groin felt more frequestronger since 10 hours ago.
Bloody show from the vagina was felt since 10 hours ago
Fluid leakage from the vagina was absent
No massive vaginal bleeding.
Amenorrhea since 8 months ago.
First date of last menstrual period was on September 1st 2012
Estimation date of delivery was on June 8th 2013
Fetal movement was felt since 3 months ago. No complain of nausea, vomiting and vaginal bleeding neither during early p
late pregnancy.
Prenatal care with midwife in primary health care every month since the agewas 4 months, fetal and mother in a good condition.
Menstruation History : menarche at 12 years old, regular cycle, once a month to 7 days each cycle with the amount of 2-3 times pad change/day without m
-
7/28/2019 Preterm Breech
6/38
Previous Illness History
There was not previous history of heart, liver, kidney, DM and hypertension. There is no histoallergy
Family Illness History : There was not history of hereditary disease, contagious and psychological illness in the family
Occupation, Socioeconomics, Psychiatry, and Habitual History :
Marriage history: once in 2012
History of pregnancy/abortion/delivery: 1/0/0
Present
History of family planning: (-) History of immunization: TT 2x on 3 and 4 month of pregnancy
History of education : Senior High School graduated
History of occupation : Housewife
History of habit : Smoking (-), Alcohol (-), Drug abuse (-)
-
7/28/2019 Preterm Breech
7/38
Physical Examination
Body Height : 155 cms
Body Weight before pregnancy : 52 kgs
Body Weight after pregnancy : 65 kgs
Body Mass Index : 22,73 kg/m2
Upper Arm Cirfumference : 24 cms
Nutrition State : Normoweight
Eyes : Conjunctiva anemic (-), sclera icteric (-) Neck : JVP 5-2 cmH2O, tyroid gland no enlarge
Chest : H/L normal
Abdoment : OR
Genitalia : OR
Extremity : Edema -/-, Physiological Reflex +/+, Pathological Reflex
GA Cons BP
Mdt CMC 120/80mmHg 9
-
7/28/2019 Preterm Breech
8/38
Obstetric
Record:
Abdomen
Inspection
Enlargement in accordance with preterm pregnancy, median line hyperpigmentation, striae grav
Palpation
L1: Uterine fundal height was palpable 4 fingers below xiphoideus processus. A hard mass was p
L2: Greatest resistance was palpable on the left side. Numerous small, irregular structure were fe
L3 : A large nodular mass was palpable, not fixed
L4 : not performed
Uterine Fundal Height : 28 cm
Estimated fetal body weight : 2015 gr
Uterine contraction : 3x/40/strong
Percution
Tympani
Auscultation
Peristaltic sound was normal, Fetal heart sound: 142-150x/i
-
7/28/2019 Preterm Breech
9/38
Genitalia
Inspection V/U normal , vaginal bleeding (-)
Inspeculo : Vagina tumor (-), lace
Portio tumor (-), laceopened 4 cm
VT : 4-5 cm
Amnionic sac (+)
Breech presentation H I
Pelvic inlet and pelvic outlet: Inner pelvic examination: Promontorium
Inominate lin
Sacrum os : co
Side walls : st
Ischial spine :
Coccygeus os
Pubic arch : >
Outer pelvic examination Inter tuberouthrough by no
Impression : Not contracted pelvic
-
7/28/2019 Preterm Breech
10/38
Laboratory Evaluation:
Result Normal Limit 3rd Trimester
Routine Blood Count
Haemoglobine 11 9.515 g/dl
Leucocyte 14.100 5.916.9/mm3
Hematocryte 32 28.040.0%
Trombocyte 339.000 146429/mm3
Eritrocyte 4.200.000 2.714.43/mm3
MCV 83 8292 m3
MCH 27,5 2731 pg
MCHC 32,1 32-36 g/dl
Urina
Protein : (-)
Glucose : (-)
Leukocyte : 0-1/lpb
Eritrocyte : 0-1/lpb
Silinder : (-)
Kristal : (-)
Epitel : (+) gepeng
Bilirubin : (-)
Urobilinogen : (+)
-
7/28/2019 Preterm Breech
11/38
Baseline : 140-150 dpm
Variability : 5-10 dpm
Acceleration : (+)
Deceleration : (-)
Impressed : Reactive CTG
-
7/28/2019 Preterm Breech
12/38
USG
Fetal alive, singleton, intra uterine, hpresentation
Fetal Movementactivity was good
Biometri :
BPD :
FL : 6
AC : Amnionic Fluid
enough
Fetal weight :2279 gr
Placenta in corpus anterior grade I-II
Impression : preterm pregnancy, Fe
alive
-
7/28/2019 Preterm Breech
13/38
Diagnose
G1P0A0 L0 preterm pregnancy34-35 weeks first stage of
active phase + labor inprogress observation
Fetal alive, singleton, intrauterine, breech presentationat HI
Management
Control GA, VS, FHS, UterineContraction
CBC, urinalysis
Antibiotic skin test
Consult anesthesia
Consult OR
Informed consent
Plan
CS
-
7/28/2019 Preterm Breech
14/38
At 01.40 pm
TPPCS was performed
At 01.45 pm
A Male baby was born byTPPCS
FW : 2200 gr
FH : 44 cm
A/S : 8/9
Placenta was delivered bysmall traction, complete, 16 x
15 x 2 cm in size, 400 gr inweight, umbilical cordslength 45 cm, insertion
paracentralis.
IUD Insertion was performed.
Blood loss during operation200 cc
Diagnose
P1 A0 L1 post TPPCS onindication Pretermpregnancy + breechpresentation + IUD
acceptor
Mother-child were incare
M
LITERATURE REVIEW
-
7/28/2019 Preterm Breech
15/38
LITERATURE REVIEW
Breech presentation
when the buttocks ofthe fetus enter thepelvis before thehead.
The incidence Conditions
contracted
uterine ano
fibroid uter
placenta pr
multiple pre
polyhydram
oligohydram
fetal spina bcannot kick
fetal goiter flex its head
a hydrocephlower segmsmall).
-
7/28/2019 Preterm Breech
16/38
The frank breech Complete breech Footl
Different kinds of breech presentations
-
7/28/2019 Preterm Breech
17/38
Engagement and descent of the breech the bitrochanteric diameter in one of the
The anterior hip usually descends more rapidly than the posterior hip when the refloor is met, internal rotation of 45 degrees usually follows, bringing the anterior hipand allowing the bitrochanteric diameter to occupy the anteroposterior diameter of
Descent continues until the perineum is distended by the advancing breech, and thethe vulva. By lateral flexion of the fetal body, the posterior hip then is forced over theretracts over the buttocks, thus allowing the infant to straighten out when the anteriand feet follow the breech and may be born spontaneously or require aid.
After the birth of the breech, there is slight external rotation, with the back turning ashoulders are brought into relation with one of the oblique diameters of the pelvis.
The shoulders then descend rapidly and undergo internal rotation, with the bisacromthe anteroposterior plane. Immediately following the shoulders, the head, which is nupon the thorax, enters the pelvis in one of the oblique diameters and then rotates ibring the posterior portion of the neck under the symphysis pubis. The head is then
CARDINAL MOVEMENTS WITH BREECH DELIVERY
Abdominal Vaginal an ultrasound
-
7/28/2019 Preterm Breech
18/38
Anamnesis
The mothermaycomplain ofpain underthe ribs.
Abdominalexamination
Leopoldmaneuver I,II,III,IV
The fetal
heart isbest heardat the levelof theumbilicus orabove.
Vaginalexamination
Frankbreech,Completebreech,footlingbreech
an ultrasoundexamination
EFW, Fetalbiometry,type ofbreech,headhyperextensionstargazing
D
I
AG
N
O
S
E
-
7/28/2019 Preterm Breech
19/38
PLANNING THE MODE OF DELIVERY
Vaginaldelivery
CS
METHODS OF
-
7/28/2019 Preterm Breech
20/38
METHODS OF
VAGINAL
DELIVERY :
1.Spontaneous breech
delivery
2.Partial breech
delivery3.Total breech
delivery
-
7/28/2019 Preterm Breech
21/38
-
7/28/2019 Preterm Breech
22/38
-
7/28/2019 Preterm Breech
23/38
-
7/28/2019 Preterm Breech
24/38
-
7/28/2019 Preterm Breech
25/38
Reducing theincidence ofbreechpresentations
External cephalic version (ECV) breech to vertex canafter 36 weeks.
Cardiotocography should be done prior to ECV.
Use of tocolysis and regional anesthesia should be co
Contraindications to ECV placenta previa, multiple pantepartum hemorrhage, small-for-dates babies, and
uterine scars, preeclampsia, or hypertension (risk of aincreased)
Theoretical risks of ECV include placental separation (cord entanglement, premature rupture of the membrprecipitation of labor
PLANNING THE MODE OF DELIVERY
-
7/28/2019 Preterm Breech
26/38
PLANNING THE MODE OF DELIVERY
According to ALARM recommendation for
breech delivery:ALARM, 2013
It recommend for trial labor in breech
presentation when gestational age 36weeks or more or when estimated birth
weight 2500 gram 4000 gram.
It offered for trial labor when gestasional
age 31-35 weeks or estimated birth
weight 1500-2500 gram
It offered for CS when gestasional age 30weeks or less or when estimated birth
weight less then 1500 gram.
It not recommended for vaginal delivery
when estimated birth weight more then
4000 gram.
If the score is 0-4, cesarean delivery
If the score > 4 , vaginal delivery is r
VAGINAL BREECH DELIVERY
-
7/28/2019 Preterm Breech
27/38
VAGINAL BREECH DELIVERY
-
7/28/2019 Preterm Breech
28/38
Preterm birth is defined as delivery before 37 completed weeks of pregnancy.
Preterm birth is a concern because babies who are born too early may not be fully developed. They may be bproblems.
The incidence of preterm birth in USA 8-10 % and in Indonesia, 16-18 % of all live birth
Academy of Pediatrics andthe American College ofObstetricians andGynecologists (1997) hadearlier proposed thefollowing criteria todocument preterm labor:Cunningham,2010
Contractions of four in 20 minutes or eight in 60 minutes plus progressive change in the cervix
Cervical dilatation greater than 1 cm
Cervical effacement of 80 percent or greater.
There are signs andsymptoms of pretermlabor : ACOG,2013
Change in type of vaginal discharge ( watery, mucus or bloody )
Increase in amount of discharge
Pelvic or lower abdominal pressure
Constant low, dull backache
Mild abdominal cramps, with or without diarrhea
Regular or frequent contractions or uterine tightening, often painless
Ruptured membranes ( your water breaks with a gush or trickle of fluid )
-
7/28/2019 Preterm Breech
29/38
Recommended Management of Preterm Labor : Cunningh
Confirmation of preterm labor as detailed in Diagnosis
For pregnancies less than 34 weeks in women with no maternal or fetal indications for delivery, close observation with monitoring of uterinand fetal heart rate is appropriate. Serial examinations are done to assess cervical changes
For pregnancies less than 34 weeks, corticosteroids are given for enhancement of fetal lung maturation
Consideration is given for maternal magnesium sulfate infusion for 12 to 24 hours to afford fetal neuroprotection
For pregnancies less than 34 weeks in women who are not in advanced labor, some practitioners believe it is reasonable to attempt in
contractions to delay delivery while the women are given corticosteroid therapy and group B streptococcal prophylaxis. Although tocolyticused at Parkland Hospital, they are given at University of Alabama at Birmingham Hospital
For pregnancies at 34 weeks or beyond, women with preterm labor are monitored for labor progression and fetal well-being
For active labor, an antimicrobial is given for prevention of neonatal group B streptococcal infection.
Prevention of Neonatal Intracranial Hemorrhage
DISCUSSION
-
7/28/2019 Preterm Breech
30/38
DISCUSSION
It has been reported a case of a 32 years old patient was adm
Emergency Room of Obstetrics and Gynecology Departmen
Djamil General Hospital on April 27th , 2013 at 12.40 pm
midwife with preterm pregnancy + breech presentation. Aftefew examination, the patient diagnosed with G1P0A0
pregnancy 34-35 weeks first stage of active phase, fetal aliv
intrauterine breech presentation HI. Then the patient underg
Peritoneal Profunda Caesarean Section. As a guide to the d
target academically comprehensive scientific then we will discthe reference question are as follows :
Whether the diagnose of this patient was right?
Whether the management of this patient was appropriate?
What the cause of preterm breech presentation in this patient
WHETHER THE DIAGNOSE OF THIS PATIENT WAS RIGHT?
-
7/28/2019 Preterm Breech
31/38
The diagnose of this patient was determined according to anamnesis, physical examexamination. From the anamnesis this patient was primigravida, and according to lais preterm pregnancy appropriate with 34-35 weeks with right assumption of the last
regular cycle without contraception before and she was in labo
Physical examination showed normal vital sign, and from Leopold, the impression was sinpresentation and the baby was alive. Through the vaginal examination,the impression wa
first stage of active phase, breech presentation HI.
From the ultrasound examination, we got impression preterm breech pregnancyof last menstrual period, gestational age is 34-35 weeks, with the uterine funda
finger below processus xypoideus. As well as biometry result from ultrasound (FL 65,3 mm, AC 295 mm and estimated fetal body weight 2279 gr ) showed pret
From all of the ananmnesis, physical examination and supportive examination hto establish the diagnosis and we can conclude that the diagnosis of this patien
WHETHER THE MANAGEMENT OF THIS PATIENT WAS A
-
7/28/2019 Preterm Breech
32/38
WHETHER THE MANAGEMENT OF THIS PATIENT WAS A
According toRCOG green top
guideline
The routine caesarean section for the delivery of ppresentation should not be advised.
According toALARM
recommendation for breech delivery, it still offer for trial lagestational age 31-35 weeks or estimated birth weight 1500patient with gestational age 34-35 weeks and estimated birso there was still a place for vaginal delivery than CS as a mthis patient.
According toZA Breech
Scoring
ZA score for this patient is 6. It means vaginrecommended.
ACCORDING TO CUNNINGHAM
-
7/28/2019 Preterm Breech
33/38
ACCORDING TO CUNNINGHAM
Malloy and co-workers (1991) studies of 437very-low-birth weight breech newborns
After adjusting for several variables, the risk ofintraventricular hemorrhage and death was
not significantly affected by the mode ofdelivery for fetuses weighing less than 1500 g.
France, Kayem and co-described neonatal ou
breech deliveries frweeksThe neonatalversus 7 percentwas
undergoing planned planned cesarean
It also said in breech presentation cesarean delivery is
commonly, but not exclusively, used in the followingcircumstances: a large fetus, any degree of contraction orunfavorable shape of the pelvis determined clinically or with CTpelvimetry, a hyperextended head, when delivery is indicated inthe absence of spontaneous labor, uterine dysfunctionsome
would use oxytocin augmentation, incomplete or footling breechpresentation, IUGR, previous perinatal death or children
suffering from birth trauma, a request for sterilization, lack of anexperienced operation
Doe to all of circumstances f
above, when we compare witpatient as follow : the estimaUSG only 2239 g, the patient
stage of active phase ), typbreech presentation, and th
pelvic clinically, but there is nhyperextended head. As a conthere was no contraindicatio
According to Alarab, M Reyan, 2004,
-
7/28/2019 Preterm Breech
34/38
g , y , ,
the diameter of bisacromial of the fetus is 11 cm , the diameter bitroch
fetus is 10 cm, the oblique diameter of the pelvic brim is 12 cm, and
diameter of outlet pelvic is 11 cm.
Based on all of the size above in breech presentation the sacrum o
bitrachanterica diameter 10 cm ) enter the pelvic birm in the left sacro an( oblique diameter of the pelvic brim 12 cm ) while the shoulder
bisacromial 11 cm ) enter and occupied the diameter transverse of the ou
cm ).
This mean the difficulty in delivering the shoulder will not happen, esp
patient with the estimated birth weight only 2015g.
However, it likely to be difficult in delivering the head, because in prehead circumferential greater than abdominal circumferential.
However, the differences of head and abdominal circumferential in
pregnancy is only 0,7 1 cm, so the possibility of difficulties in deliverin
this patient is small.
Therefore in this patient we can offer trial for pervaginam delivery.
ACCORDING TO SEVERAL STUDIES THAT NOT SUPPORTING CAESAREA
-
7/28/2019 Preterm Breech
35/38
ACCORDING TO SEVERAL STUDIES THAT NOT SUPPORTING CAESAREA
PRETERM BREECH PRESENTATION
Wolf H et al,
1999
The authors concluded that operative delivery of a fetus in breech prespreterm cases was not associated with increased survival without disaband that routine caesarean section is therefore not recommended.Wolf H
Cibilis LA etal, 1994
Evidently, the route of delivery did not significantly influence outcome aand frank breeches, while abdominal delivery might offer some benefitbreeches.Cibilis LA et al, 1994
Sthol HE etal, 2011
Thus, caesarean section was apparently associated with higher maternano neonatal benefits. Sthol HE et al, 2011
-
7/28/2019 Preterm Breech
36/38
Based on several data above , choosing mode of delivery forpreterm breech with gestational age 34-35 weeks and birth
2500 gram, there is still a place for vaginal delivery. Finally I cathat the management of this patient by performed cesarean s
mode of delivery is less precise, but not incorrect.
WHAT THE CAUSE OF BREECH PRESENTATIIN THIS PATIENT?
-
7/28/2019 Preterm Breech
37/38
IN THIS PATIENT?
Based on anamneses, physical examination and
supportive examination of this patient we canexclude the causes as fhas been mentionedpreviously .
This patient is primiparous with gestational age 34-35 weeks and estimated birth weight 2015 gr.
The cause of breech presentation in this patient is
because preterm gestational age., at 34-35 weekspregnancy amnionic fluid still in great quantities,and doe to the fetal weight small so that the fetuscan freely move.Cunningham,2003 It could be the factorthat caused breech presentation for this patient
-
7/28/2019 Preterm Breech
38/38
CONCLUSION
The diagnosis in thispatient was correct
Management in thispatient was less
appropriate
The possibilityof breech
presentation fpatient is du
preterm gestaage.