Breech Presentation 12.pptxggggbcxxxcccc

Breech presenatation

1. BREECH PRESENTATION 1

2. Breech presentation Breech presentation is a longitudinal lie of the fetus with the caudal pole (buttock or lower extremity) occupying the lower part of the uterus and cephalic pole in the uterine fundus . Incidence depend on GA / birth weight 28-32 weeks → 25% 32-34 weeks → 20% 34-36 weeks → 8% >36 weeks → 3-4 MG Twin first breech → 25% Twin second breech →50% 2

3. The breech typically enters the inlet with the bitrochanteric diameter. Sacrum is the point of designation. Eg . This is a case of left sacrum posterior (LSP ). 3

4. Types of Breech Presentations Three types Frank breech Complete(Flexed) breech Incomplete or footling breech 4

5. Frank breech The fetal hips are well flexed and knees are completely extended. Only the buttocks are felt on pelvic exam well applied to the cervix. Commonest – 65% The risk of labor abnormalities, cord prolapse and operative deliveries are lowest in the frank breech. Cord prolapse risk similar to vertex – 1% 5

6. Complete(Flexed) breech Both the fetal hips and knees are well flexed. On vaginal exam, the feet being felt Least common of breech presentations – 10% Risk of cord prolapse- 5% Risk of labor complications including prolonged labor much higher than frank breech 6

7. Incomplete (footling breech) Both hips and knees are partially flexed or knees may even be extended. The lowermost structure felt on vaginal exam is one or both feet ( single or double footling breech presentation) Second commonest type of breech presentation- 25% Highest risk of cord prolapse- 15% All protocols recommend caesarean delivery in footling breech presentations. 7

8. Incidence of different breeches Frank (65%) > footling (25%) > complete (10%) → for > 2.5kg Footling (50%) > frank (40%) > complete (10%) → for < 2.5kg 8

9. Risk factors of Breech Presentations Maternal factors Family history of breech Past history of breech (10% in next and 28% in subsequent pregnancy) Uterine congenital abnormalities Uterine myoma Grand multiparty Contracted maternal pelvis Preterm labor and delivery 9

10. Fetal factors Fetal macrosomia Multifetal gestations – mostly second twin Extreme of amniotic fluid Placenta previa Hydrops fetalis Fetal anomalies- e.g. hydrocephalus, anencephally 10

11. Diagnosis of a Breech Presentation Parameter Findings History larger degree of discomfort in the epigastrium in breech Family history or previous history of breech. Physical Exam- Abdomen Hard , round, ballotable mass in the fundus. FHB better auscultated above the umbilicus. A soft, broad, indefinite and non ballotable mass (the breech) occupying the lower pole of the uterus Physical Exam- Pelvis Ischial tuberocities , sacrum and its spines, genitals and the anus (are usually palpable in frank breech) Ischial tuberosity and anus are in straight line (where as the malar eminence & mouth form a triangle in face presentation) Search carefully for cord presentation. Estimate pelvic capacity by clinical pelvimetry. 11

12. Ultra- Sonography Confirm the diagnosis Estimate fetal size Assess attitude of fetal head to rule out hyperextension of the head Assess placental localization Assess adequacy of amniotic fluid Check the biophysical profile to assess fetal well being 12

13. Management of breech Antenatal management Management during labour 13

14. Antenatal management of breech 1.Spontaneous version Most important intervention is facilitation of conversion to vertex by various methods Spontaneous version may occur at any time before delivery, even after 40 wks -60% after 32 weeks, 25% after 36weeks. -Increase in multipara with no previous history. -Less likely in –Nullipara ,Extended legs ,Oligohydram ,Fetal or uterine anomalies 14

15. 2. External cephalic version Version is a procedure in which the fetal presentation is altered by physical manipulation, either substituting one pole of a longitudinal presentation for the other or converting an oblique or transverse lie into a longitudinal presentation. The goal of ECV is to increase the proportion of vertex presentations among fetuses that were formerly in the breech presentation near term. 15

16. Once a vertex presentation is achieved, the chances for a vaginal delivery increase. Is cost effective method in comparison with operative delivery. Several organizations recommend ECV WHO RCOG ACOG Effectiveness : 35-85%, average 60% ( ACOG 2000 ) 16

17. Timing of ECV ACOG recommend prior to labor & G.A. >   36wks. Advantages of ECV at or near term are: usually successful, likely to remain cephalic after successful ECV. fetus is mature or nearly mature in the event necessitating urgent C/S. Earlier attempts > successful, & > spontaneous reversion back to breech. Don’t perform before 37weeks (WHO) 17

18. Contraindication for ECV Absolute - multiple gestation - IUGR, IUFD ,major anomaly - Hyperextended head - APH - PROM - Abnormal CTG - PIH - Classical C/S - Uterine malformation -Cord around the neck -Consent declined -Indications for C/S Relative - Macrosomia - Maternal obesity - 2 or more LUSTC/S - Active labor - Unstable lie - RH- iso immunization - Grand multipara - Ant. Placenta - MTCT - Decreased AFV -Elderly primigravida 18

19. Prerequisites Ultrasound evaluation - confirm the Dx , Exclude cong. Anomalies, AFV & Placenta location. Documentation of fetal well-being. Informed consent: PTL, ROM,cord and placental accident Availability of C/S Skilled operator No C/I The patient should be NPO for at least 8 hours prior to the procedure. Bladder should be emptied 19

20. Technique Of ECV U/S: confirm the diagnosis, Exclude cong. Anomalies, AFV & Placenta location External monitoring is performed to assess FHR reactivity. Tocolysis: usually terbutaline can be given 15-30 min, prior to the procedure. ACOG (2000): not enough evidence to recommend conduction analgesia routinely. Do NST/BPP to asses fetal wellbeing Inform to relax muscles & report if any discomfort. 20

21. Disengaged from the pelvis by slowly inserting fingertips of both hands deeply in the Suprapubic area Auscultate FHB Q 2 minutes A NRFHRP leading to discontinuation occur in~ 5 % of cases Limit applying pressure on the uterus for 5min 21

22. Forward or backward version 22 Disengage the breech One hand in lower pole and other in the upper pole Manipulate in the direction which increase fetal flexion Do forward roll then if not successful do backward roll. Stabilize after version with lateral pressur e

23. Discontinue ECV when Excessive maternal discomfort Persistent FHR abnormality If multiple failed attempts ( >3) If unsuccessful after 5 min, the procedure is interrupted and the women rest in her side for two min before repeat attempt. 23

24. Following ECV, whether successfully or not ,repeat NST or BPP prior to discharge Administer Anti-D If unsuccessful ECV , send her home or proceed with C/S vs planned vx delivery No support of routine induction to minimize reversion. 24

25. Risks of ECV Fetal trauma - fractured fetal bones precipitation of labor Premature rupture of membranes Amniotic fluid embolism Abruptio placentae Feto maternal hemorrhage (0-5%) Cord entanglement ( <1.5%) Intrauterine fetal demise (Cord accident, unexplained etiology) Transient slowing of the fetal heart rate 25

26. Success of ECV Predictor of success Parous (52-95%) Transverse/Oblique lie Unengaged, mobile Palpable fetal head Flexed>>frank Lateral position of the fetal spine Predictor of failure Null parity (26-62%) Tense uterine tone Maternal Obesity Anterior Placenta Fetal wgt < 2500g Engaged fetus Incomplete breech Ant. or posterior spine Dec AFV or ROM 26

27. Breech presentation diagnosed before 36 weeks of GA  manage expectantly. Internal podalic version done only for Retained second twin with fetal distress For a small dead fetus in a transverse lie 27

28. Criteria for VD or CS VD Frank GA>34w EFW=2000-3500gr Adequate pelvis Flexed head Nonviable / previable fetus Good progress labor No indication for c/s Lethal congenital abnormality Presentation of mother in advanced labor with no fetal or maternal distress CS Footling / complete GA24-34w EFW<1500or> 3500gr Contracted or borderline pelvis Deflexed (hyper extended) head Fetal distress dysfunctional labor Elderly Primi Mother with hx of infertility or bad obstetric hx Prolonged rupture of membrane Unengaged presenting part IUGR or any placental insufficiency 28

29. Zatuchni -Andros Breech Scoring If the score is 0-4, cesarean delivery is recommended. Decision regarding mode of delivery should depend on the experience of the health care provider 29 Add 0 Points Add 1 Point Add 2 Points Parity 1 2 Gestational age ( wk ) 39+ 38 <37 EFW ( lb ) 8 7-8 <7 Previous breech 1 2 Dilatation 2 3 4 Station -3 -2 -1

30. Labor Management First stage of labour Necessary staff includes: a provider skilled in the art of breech extraction an associate to assist with the delivery anesthesia personnel who can ensure adequate analgesia or anesthesia when needed, and an individual trained in newborn resuscitation. 30

31. On admission: the status of the membranes and progression of labor are assessed cervical dilatation, cervical effacement, and membrane status is essential for preparation During labor, one-on-one midwifery care is ideal because risk of cord prolapse Secure IV line Consider analgesics as labor pain management Immediate vaginal examination at rupture of membranes to rule out cord prolapse 31

32. Avoid ARM Meconium is common with breech presentation and presence of meconium alone is not considered as a sign of fetal asphyxia. The mother should be instructed not to push until the cervix is fully dilated. Augmentation of labor is contraindicated in breech presentation 32

33. Continuous electronic monitoring Intermittent auscultation recorded at a minimum of every 15 minutes. If NRFHR pattern develops, then a decision must be made regarding the necessity of cesarean delivery . 33

34. Types of Vaginal Breech Delivery Spontaneous vaginal breech delivery Assisted breech delivery (partial breech extraction Total breech extraction 34

35. 1. Spontaneous vaginal breech delivery Delivery of the breech without any assistance and only by maternal effort. E.g . A small breech in a multiparous mother 35

36. 2. Assisted breech delivery (partial breech extraction) Delivery of the breech by maternal effort but targeted assistance provided by the labor attendant to assist in specific instances through deliberate maneuvers. Body deliver spontaneously up to the level of the umbilicus operator assists in delivering: legs, shoulders, arms, & head. Delivery is easier, morbidity & mortality are probably lower, when allowed to deliver spontaneously to the umbilicus . 36

37. Steps in assisted breech delivery Delivery of the buttocks and legs : Once the buttocks have entered the vagina and the cervix is fully dilated, tell the woman she can bear down with the contractions. If the perineum is very tight, perform an episiotomy. Let the buttocks deliver until the lower back and then the shoulder blades are seen. Gently hold the buttocks in one hand, but do not pull. 37

38. Delivery of the buttocks and legs… If the legs do not deliver spontaneously, deliver one leg at a time: Push behind the knee to bend the leg; Grasp the ankle and deliver the foot and leg Repeat for the other leg Pinard maneuver To deliver extended legs/Frank breech, place index finger in popliteal fossa of 1 leg and apply pressure upward and outward, causing knee to flex 38

39. Delivery of the buttocks and legs… Put fingers on the anterior superior iliac crests and thumbs on the sacrum to apply downward rotational traction Use a dry towel to wrap around the hips Do not hold the baby by the flanks or abdomen as this may cause kidney or liver damage. 39

40. Delivery of the arms: Arms are felt on chest:- Allow the arms to disengage spontaneously one by one After spontaneous delivery of the first arm, lift the buttocks towards the mother's abdomen to enable the second arm to deliver spontaneously If the arm does not spontaneously deliver, place one or two fingers in the elbow and bend the arm, bringing the hand down over the fetus‘s face 40

41. Delivery of the arms… Arms are stretched above the head or folded around the neck : Use the Lovset‘s manoeuvre Hold the fetus by the hips and turn half a circle, keeping the back uppermost and applying downward traction at the same time, so that the arm that was posterior becomes anterior and can be delivered under the pubic arch. Assist delivery of the arm by placing one or two fingers on the upper part of the arm. 41

42. Draw the arm down over the chest as the elbow is flexed, with the hand sweeping over the face. To deliver the second arm, turn the baby back half a circle, keeping the back uppermost and applying downward traction, and deliver the second arm in the same way under the pubic arch. 42

43. 43

44. 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. Move the baby‘s chest towards the woman‘s inner leg. The shoulder that is posterior should deliver. Deliver the arm and hand. Lay the baby back down by the ankles. The shoulder that is anterior should now deliver. Deliver the arm and hand . 44

45. 45

46. Delivery of the After coming Head No time for Molding: Even moderately narrow pelvis can pose difficulty of delivery Hyperextended head referred to as stargazer fetus , & in Britain as the flying fetus . 5% of term BP: If identified is an indication for C/S delivery( X-ray, U/S) 46

47. Delivery of the After coming Head … Maneuvers for Delivery of the After coming Head MSV M odified prague Burns Marshal Pipers forceps 47

48. Delivery of the Aftercoming Head… 1.Mauriceau – Smellie - Veit (MSV) Maneuver Lay the baby face down with the length of its body over your hand and arm. Place the first and third fingers of this hand on the baby‘s cheekbones and place the second finger in the baby‘s mouth to pull the jaw down and flex the head. Use the other hand to grasp the baby's shoulders . 48

49. With two fingers of this hand, gently flex the baby‘s head towards the chest, while applying downward pressure on the jaw to bring the baby‘s head down until the hairline invisible. Pull gently to deliver the head. Note: Ask an assistant to push above the mother‘s pubic bone as the head delivers. This helps to keep the baby‘s head flexed. Raise the baby, still astride the arm, until the mouth and nose are free 49

50. Delivery of the After coming Head … 2.Prague Maneuver : Rarely, the back of the fetus fails to rotate to the anterior. Two fingers of one hand grasping the shoulders of the back down fetus, from below, while the other hand draws the feet up over the abdomen of the mother. 50

51. Delivery of the After coming Head… 3. Burns-Marshall Maneuver: Baby allowed to hang on its weight , assistant gives suprapubic pressure in down ward & back ward direction Pressure more exerted towards the sinciput Purpose: promote flexion of the head When the nape of the baby is visible under the pubic arch, baby grasped by the ankles with finger in b/n the two. Maintaining a steady traction & forming a wide arc of a circle, the trunk is swung in upward & forward direction. 51

52. Delivery of the After coming Head… 4 . Pipers forceps Specialized forceps called Piper forceps or divergent Laufe forceps can be used if the MSV maneuver fails. Blades are applied when the head is brought in to the pelvis. Suspension of the body of the fetus in a towel effectively holds the fetus & helps keep the arms out of the way. 52

53. Entrapment of the After coming Head Common in preterm Disparity b/n the size of the head & buttocks is even greater than with a larger fetus Buttocks & lower extremities pass through the Cervix, & yet the Cervix will not be dilated adequately for the head to escape without trauma Some recommended IV nitroglycerin typically 100g to provide Cervix relaxation for relief of head entrapment 53

54. Entrapment of the After coming Head… Dührssen incisions of the Cervix : at 2, 6 and 10 o'clock 54

55. Entrapment of the After coming Head… Zavanelli maneuver —cesarean delivery after replacement of the fetus back into the uterus Symphysiotom to widen anterior pelvis. Splitting the symphysis pubis The skin over symphysis pubis and fibrocartilaginous area infiltrated with local anesthetic. The urethra displaced laterally using index and middle fingers placed against the posterior aspect of symphysis and incision made through cartilaginous portion of symphysis. 55

56. 3.Total breech extraction Complete delivery conducted by the provider without maternal effort In modern obstetrics practice, this procedure only reserved when expedited delivery is mandatory: Fetal distress and cord prolapse in the second stage of labor requiring immediate delivery. Delivery of twin B in a non vertex position following successful VD of twin A. Has been virtually replaced by C/S delivery in modern obstetrics 20% are injured during total breech extraction 56

57. A: Abduction of thigh and pressure in popliteal fossa cause the knee to flex & become accessible. B: Delivery of leg by traction on the foot 57

58. A : Buttocks brought to hollow of sacrum. B: Traction on anterior leg causes buttocks to advance and rotate into direct AP diameter of pelvis. Continued downward traction causes the back to rotate anteriorly. C: Further downward traction causes the shoulders to engage in the transverse diameter of the inlet 58

59. Complication of breech Maternal complication Increased maternal mortality and morbidity Discomfort and sub costal pain Prolonged labor Increased manipulation and trauma Puerperal sepsis High incidence of C/S rate 59

60. Complication of breech… Fetal complication Increased fetal mortality and morbidity Lower Apgar score An entrapped head Nuchal arms Cervical spine injury Cord prolapse Intracerebral , or intraventricular hemorrhage Skull fracture  Peripheral nerve injury 60

61. THANK YOU 61