ASSISTED BREECH DELIVERY Dr. Kavitha.pptx

Assisted breech delivery

1. ASSISTED BREECH DELIVERY By Assistant Professor Dr. Kavitha M MS OBG

2. With a cephalic presentation , once the head is delivered, the rest of the body typically follows without difficulty. With breech , however, successively larger and less compressible parts are born last. Spontaneous complete expulsion of fetus that presents as breech is seldom accomplished successfully.

3. MANAGEMENT OF DELIVERY OF BREECH PRESENTATION

4. VAGINAL DELIVERY Spontaneous breech delivery : The entire infant is expelled by natural forces of the mother with no assistance other than support of the baby as it is born Assisted breech delivery : The fetus is delivered spontaneously as far as the umbilicus, but the remainder of the body is delivered with assisted maneuvers, with or without maternal expulsive efforts. Total breech extraction :the entire body of the infant is extracted by the obstetrician CAESEREAN SECTION

5. ZATUCHINI-ANDROS PROGNOSTIC SCORING(1967) Most popular scoring system for assessing the prognosis of successful vaginal delivery.

6. 1 2 PARITY primi multigravida GESTATIONAL AGE >39 weeks 38weeks 37 weeks ESTIMATED FETAL WEIGHT >3.5kg 3-3.5kg <3kg PREVIOUS BREECH DELIVERY >2500g none 1 >2 CERVICAL DILATATION <2cm 3cm > 4cm STATION OF BREECH > - 3 -2 < -1

7. Score 3 or less : CESAREAN SECTION Women with higher scores can be allowed for VAGINAL DELIVERY .

8. INDICATIONS FOR VAGINAL DELIVERY Frank or complete breech presentation Gestational age >36 weeks Estimated fetal weight 2.5 to 3.5kg Fetal head must be flexed Adequate maternal pelvis. No other obstetric complications Good ZA score

9. MANAGEMENT OF FIRST STAGE OF LABOUR

10. An iv line is started preferably with ringer lactate. Vaginal examination is indicated - at the onset of labour for pelvic assessment - soon after rupture of membrane to exclude cord prolapse Blood is sent for grouping and matching Patient with term breech presentation is advised to stay in bed. (to prevent PROM)

11. Adequate analgesia is given , epidural is preferred. Fetal heart rate monitored by CTG . Monitoring progress of labour by PARTOGRAM Oxytocin infusion may be used for the augmentation of labour.

12. MANAGEMENT OF SECOND STAGE OF LABOUR

13. Spontaneous breech delivery Assisted breech delivery Total breech extraction

14. ASSISTED BREECH DELIVERY Ideally, the breech is allowed to deliver spontaneously upto the umbilicus. This is the most common mode of vaginal breech delivery. This is a “ HANDS OFF TECHNIQUE ”. MASTER INACTIVITY WATCHFUL EXPECTENCY Certain manoeuvres are initiated by the obstetrician to aid delivery of the remainder of body , arms and head.

15. PREREQUISITES The back should always be anterior Fetus should not be pulled from below . Baby’s body covered by sterile towel –prevents premature attempt of inspiration due to external cutaneous stimuli Fetus head should always be maintained in flexion.

16. ASSISTED BREECH DELIVERY STEPS Wait for the legs to deliver spontaneously. (or hook out the legs) With increasing uterine contractions the breech emerges out of the vulval outlet. Local infiltration anaesthesia is given and mediolateral episiotomy is done. After the decent of the breech into the pelvic floor, once climbing of perineum takes place

17. FEMORAL PELVIC GRIP : bony pelvis is grasped with both hands using a warm towel. Fingers on the anterior superior iliac spine Thumb on the sacrum. Maternal expulsion efforts. Steady, gentle downward traction is applied until the lower halves of the scapula are delivered. Appearance of one axilla indicates the time for shoulder delivery.

18. DELIVERY OF THE SHOULDER Attempt is made for the delivery of the shoulder when one axilla is seen at the pubic symphysis. Ordinarily, the arm being flexed at the elbow the shoulders deliver without much difficulty. Posterior arm is delivered first followed by anterior arm .

19. DELIVERY OF THE HEAD After the shoulders are delivered. The back of the fetus is in the direction of the symphysis which is followed by the assisted delivery of the head. Hairline is seen under the symphysis.

20. MARSHALL BURNS TECHNIQUE MODIFIED MAURICEAU SMELLIE VEIT PROCEDURE FORCEP’S DELIVERY

21. MARSHALL BURNS TECHNIQUE The baby is allowed to hang by its own weight. Suprapubic pressure is given in the downward and backward direction. KRISTELLAR MANUEVRE

22. When nape of the neck is visible under the pubic arch, the baby is grasped by the ankle with a finger between the two. Maintaining traction the trunk is swung in upward and forward direction. The other hand to guard the perineum.

23. MODIFIED MAURICEAU SMELLIE VEIT PROCEDURE

24. Suprapubic pressure is applied simultaneously which also helps keep the head flexed. Two fingers of the other hand then are hooked over the fetal neck , and grasping the shoulder downward traction is applied concurrently until the subocciput region appears under symphysis. The index and middle finger of one hand is applied over the maxilla to flex the head while the fetal body rests on the hand and forearm. Delivery of the head via flexion

25. MAURICEAU SMELLIE VEIT MANEUVER suprapubic pressure by one obstetrician on the mother’s uterus while another obstetrician inserts left hand in vagina, placing 2 fingers on the malar prominences and another finger in the fetus mouth This maneuver is named after FRANCOIS MAURICEAU, WILLIAM SMELLIE,GUSTAV VEIT.

26. The left hand's palm should rest against the fetus' chest, the right hand can grab either shoulder of the fetus and pull in the direction of the fetus' pelvis.

27. FORCEPS DELIVERY PIPER’S FORCEPS

28. Fetal body is elevated using a warm towel . Left blade of the forceps is applied to the aftercoming head . Right blade is applied with the body still elevated . Locking the blades. Application of traction with the obstetrician is kneeling down position. The fetus head is delivered by pulling gently outwards and raising the handles simultaneously.

29. MANAGEMENT OF COMPLICATED BREECH DELIVERY

30. FRANK BREECH EXTENDED ARMS NUCHAL ARMS OCCIPITOPOSTERIOR POSITION OF HEAD

31. FRANK BREECH

32. PINARD’S MANUEVER One hand is introduced into the vagina, fingers are guided along the posterior aspect of the knee.

33. Gentle pressure is exerted in the popliteal space. This causes the leg to flex at the knee . The foot is grasped and brought down to the vulva

34. EXTENDED ARMS LOVSETT MANEUVER

35. LOVSET MANEUVER The trunk is rotated so that the anterior shoulder and arm appear at the vulva and a finger is passed along the arm down to the elbow which is flexed and the hands drop down.

36. Then the body is rotated 180 degree in the reverse direction to deliver other shoulder and arm.

37. NUCHAL ARMS Nuchal arms denotes that the hand is behind the occiput. One or both hands may be in this position. (flexed at the elbow and extended at the head) Incidence : 0-5% of vaginal breech deliveries The diagnosis is made when the obstetrician notices that the medial border of the scapula is not parallel to the spine .

38. After grasping the baby at pelvic girdle with thumbs on sacrum Rotated 180 degree towards the fingertips of trapped arm Lovset maneuver

39. OCCIPITOPOSTERIOR POSITION OF HEAD

40. MODIFIED PRAQUE MANEUVER In rare cases the fetus fails to rotate anterior, in such cases the fetus maybe delivered by this method. Two fingers of one hand grasping the shoulders back down fetus from below. Other hand draws the feet up and over the maternal abdomen.

41. TOTAL BREECH EXTRACTION INDICATIONS NONCEPHALIC PRESENTATION OF THE SECOND TWIN ONCE THE FIRST TWIN HAS DELIVERED. FETAL DISTRESS CORD PROLAPSE

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