BREECH DELIVERY.pptx

Breech presentation

1. BREECH DELIVERY B y A b d u l w a h i d K o r a n e J a b i r A d e n A b d i

2. Definition Epidemiology Types of Breech R i s k f a c t o r s Diagnosis Management Complication CONTENT

3. Breech presentation is when the fetal buttocks or lower extremities present first into the maternal pelvis. The lie is longitudinal, and the head is found in the fundus .. Breech Birth is a birth of a baby from a breech presentation, in which the baby exits the pelvis with the buttocks or feets first as opposed to normal head first presentation. DEFINATION

4. Its The commonest abnormal presentation . Occurs 3-4% of all pregnancies and increases with decreasing gestational age. 7-10% at 32 Wks. 25- 35% at at < 28 Wks. Normal in preterm when the fetus is more mobile, therefore it should not be taken as abnormal until late pregnancy. EPIDEMIOLOGY

5. Frank breech: O c c u r s ( 7 % ) w h e n b o t h f e t a l t h i g h s a r e f l e x e d a n d b o t h l o w e r e x t r e m i t i e s a r e e x t e n d e d a t t h e k n e e s . Its more common in PG. Complete breech: ( 2 % ) both knees and hips are flexed, feet not below the level of buttocks. Common in Multipara . 3. incomplete or footling breech: ( 1 % ) The hip and knee joints are extended on one or both sides. There is High Risk of cord and Foot prolapse. TYPES OF BREECH

6. Breech presentations: A: Right sacrum posterior (RSP) position B: Left sacrum anterior (LSA) position

7. MATERNAL Uterine and Pelvic tumors. Polyhydramnios and Oligohydramnios. Uterine anomalies Placental anomaly like praevia Breech Presentation In previous pregnancy. Contracted pelvis Multiparty especially Grand multiparas. R i s k f a c t o r s

8. FETAL Prematurity IUFD Macrosomia Fetal Anomalies such as Hydrocephalus, Anencephally . Cont.

9. INSPECTION : Abdomen appears asymmetrical, , Difficult to feel Fetal part, There is positive fluid thrill. PALPATION: longitudinal lie, Hard at the fundus, and broad at the lower pole . Complains of discormfort under the ribs due to pressure of the head on diaphragm. AUSCULTATION : FHS heard above the umbilicus . With legs extended breech descents into the pelvis easily making the fetal heart to be heard at a lower level. V/E: soft buttock felt, feet is in the pelvis. ULTRASOUND: Confirms Breech presentation. ANTENATAL DIAGNOSIS

10. External Cephalic Version ( ECV) Vaginal Breech Birth Caesarean Section MANAGEMENT

11. External cephalic version (ECV) is a method for manually turning a breech or transverse presentation into a cephalic one. It is performed from 36wks in nulliparous women and 37wks in multiparous ones. The intention is to reduce the need for delivery by CS . METHOD/PROCEDURE 1.Do an U/S to Exclude fetal anomalies, Confirm presentation and Attitude of fetal head. After USS , The woman is lied flat with a left lateral tilt (ensure her bladder is empty) and she's comfortable. Breech is elevated from the pelvis and one hand used to manipulate this upward in the direction of a forward role while the other hand applies gentle pressure to flex the fetal head and bring it down to the maternal pelvis. External cephalic version

12. Procedure is uncomfortable for the mother and shouldn't ’ exceed 10 minutes . If procedure becomes difficult, its abandoned. Fetal heart rate trace must be performed before and after the procedure and Anti-D is administered if the woman is rhesus negative. 2. PELVIMETRY to assess the Sacral Curve and measure the outlet and inlet. 3.HISTORY TAKING to exclude Contraindications Criteria For ECV, if not contraindicated do an ECV. Facilitation : success rates are increased by the use of tocolysis (anti-contraction),such as salbutamol,nifedipine, nitroglycerine, indomethacin given either electively or if a first attempt fails. Epidural or spinal analgesia are not usually used. Safety : approximately 0.5% will require immediate delivery by CS due to fetal heart rate abnormalities or vaginal bleeding. Theoretical or minor risks include pain, precipitation of labor, placental abruption, fetomaternal hemorrhage, and cord accidents. The chances of CS during labor are slightly higher than with a fetus that has always been cephalic.

13. External cephalic version

14. CONTRAINDICATIONS OF ECV ABSOLUTE Fetal abnormality e.g. hydrocephalus Placental Previa ( Low lying) A m n i o t i c f l u i d abnormality(Oligohydramnios ) Suspected IUGR Previous caesarean or myomectomy scar on the uterus. PROM RELATIVE Multiple gestation Maternal hypertension. COMPLICATIONS OF ECV Premature labor Premature rupture of the membrane. Hemorrhage Fetal Distress Baby may turn Back to Breech after ECV has been done.

15. TYPE OF DELIVERY Vaginal delivery: Spontaneous Partial breech extraction Total breech extraction Cesarean delivery CON’T MGT

16. Spontaneous breech (rare) : No manipulation of the infant is necessary, other than supporting the infant. It occurs predominantly in very preterm deliveries. Partial breech extraction : Fetus descend spontaneously to where umbilicus is at the vaginal introitus; then , maneuvers are initiated to assist in the delivery of the remainder of the body, arm and the head of the fetus is extracted completely Total breech extraction : The entire body of fetus is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible. TYPES OF VAGINAL BREECH DELIVERY

17. VAGINAL BREECH DELIVERY PREREQUISITES FOR VAGINAL BREECH DELIVERY Presentation should either be extended( hip flexed, knees extended) or flexed (hips flexed, knees flexed but feet not below the fetal buttocks) No previous Caesarean Section For C e p h a l o p e l v i c d i s p r o p o r t i o n . The fetus should not be too large. Ensure Adequate Clinical pelvimetry. Should be in a Hospital with Facilities for Caesarean Section. Ensure adequate analgesia Spontaneous descent and expulsion to the umbilicus should occur with maternal pushing only. Episiotomy may be considered once the anterior buttock and anus are crowning. Experienced Obstetricians. In IUFD

18. Large Baby Prime Gravida Previous C-Section Advanced Maternal age Small pelvis on pelvimetry Poor Obstetric history Footling Breech CONTRAINDICATIONS TO VAGINAL BREECH DELIVERY

19. Call for: 1. Experienced midwife 2. Obstetric Registrar 3.Neonatal Registrar 4. Anesthetic Registrar PROCEDURE

20. Set IV Lines. Obtain blood for CBC, Grouping and Cross matching. Continuous c a r d i o t o c o g r a p h y ( C T G ) Monitoring. Empty the Bladder and Rectum. Consider Epidural analgesia. Put the patient in lithotomy. Do V/E to confirm Cervical dilatation and look for cord presentation. FIRST STAGE

21. 1.Delivery of buttocks, leg and lower body Once the but t o c ks ha v e e nt e red the v a gi n a te l l the woman s h e c an b e ar d o wn with t h e c o nt r a c ti o n s . Maternal expulsion delivers the frank breech from the lower birth canal, while the contractile forces of the uterus maintain flexion of the foetal head. SECOND STAGE

22. Let the bu t to c ks de l iv e r u nt i l the l o wer ba c k and th e n the s h o u l d er b l a d es a r e s e e n. Gently ho l d t h e butt o c k s in o n e h an d but do n o t pul l . If the l e gs do n o t d e l i v er s p o nt a n e o u s l y, d e li v er o n e leg at a tim e , Its called Pinard’s manoeuvre. Do t h is by s p li n ti n g t he t h i g h w h il s t fle x i n g a nd a b d u c t i n g the h i p.

23. At this point the breech should hang downwards, while maternal efforts expel the infant until the lower border of the scapula is visible below the pubic arch. Wrap the baby in a sterile towel or cotton wool and hold by the hips. Do not hold the baby by the flanks or abdomen as this may cause kidney or liver damage. Gentle support by the clinician ensures the back does not rotate posteriorly.

24. For delivery of the shoulders and arms, the clinicians thumbs overlie the sacrum with the fingers around the iliac crests, so that the hands cradle the foetal pelvis. 2.Delivery of shoulder

25. Allow the arms to disengage spontaneously one by one. Only assist if necessary. If the foetal arms have not become extended, the clinician passes the index and middle fingers over the shoulder, and sweeps the left arm medially across the chest, thus delivering it. Repeat for the right arm.

26. If the foetal a r ms h a v e e x t e n d e d, the c l i n i c i a n a p p l i e s Lo v s e t's m a n o e u v r e.

27. The clinician rotates the body with the back uppermost, 180 degrees . The posterior shoulder has been rotated anteriorly, and lies beneath the symphysis Pubis. The clinician hooks the arm downwards, then rotates the body back 180 degrees, to deliver the other arm in the same manner. If the baby’s body cannot be turned to deliver the arm that is anterior first, deliver the shoulder that is posterior. Hold and lift the baby up by the ankles.

28. Move the baby’s chest towards the woman’s inner leg. The shoulder that is posterior should deliver.

29. Lay the baby back down by the ankles. The shoulder that is anterior should now deliver. Gentle elevation of the foetal trunk allows the clinician to access to the foetal airway. You must avoid over-extension, because of the risk of fetal cervical injury, and hyperextension of the foetal head.

30. Del i v e r t he h e ad by the Ma u ri c e a u Smell i e Veit manoeuvre. L a y the b a by f a ce d o wn with the l e n g th of its b o dy o v er y o u r ha n d a n d a rm. Pla c e the f i r s t a n d t h i rd f i n g e r s of th i s ha n d on the b a b y ’s c h e e k b o n es a n d p l a ce t h e s e c o n d fi n g e r be n e a th the c h i n, e a se t h e c h e e k s down and fl e x the h ead. Use the o t h e r h a n d t o g r a sp t h e baby’s s h o u l d e r s. 3.Delivery of head

31. With two f i n g e rs of th i s h a n d , g e n tly fl e x the baby’s head towards the chest while applying downward pressure on the chicks to bring the baby’s head down until the hairline is visible. Pull gent l y t o deli v er the h e ad.

32. MATERNAL Prolonged labor with maternal distress. Obstructed labor. Laceration especially perineal Tear. PPH due to prolonged labor and lacerations. Puerperal sepsis. Complications of Vaginal breech delivery

33. FOETAL Cord prolapse. Birth trauma as a result of extended arm or head, incomplete dilatation of the cervix or CPD . Asphyxia from cord prolapse, cord compression, placental detachment or arrested head. Damage to abdominal organs. Broken neck. CON’T

34. T h a n k y o u