breech presentation

nsg

1. Mittal college of nursing Ajmer Topic= mal presentation ( breech presentation ) Subject = obstetric and midwifery Presented by , Miss Rekha rawat Bsc. Nursing 4h year Presented to , Mrs. Snehlata parashar Lecturer of obg.and gyne . Submit date = 02/04/2019

2. Introduction FETAL PRESENTATION = It is refers to the part of the fetus that is overlying the maternal pelvic inlet. MAL PRESNTATION =Except vertex ,all are considered malpresentation. Mal position = abnormal positioning of fetus at the time of delivery .

3. The malpresentations are (1) occipito posterior position (2) Face presentation (3) Brow presentation (4) Breech shoulder (5) Compound presentation (6) Unstable lie

4. Occipito posterior presentation Face presentation

5. Brow presentation Shoulder presentation Compound presentation

6. definition Breech Presentation is the Presentation in which the Fetus in a longitudinal lie with the buttocks or feets closet to the cervix .

7. incidence *The percentage of breech delivery decrease with advancing gestational age from 22-25 % of birth prior to 28 weeks . * 3-4% of fetus present by breech at term *5% at 34 weeks , usually 3 in 100 (3%) *20% at 28 weeks . *20% diagnosed initially in labor. *The higher incidence of breech in earlier weeks of pregnancy.

8. etiology 1=MATERNAL FACTORS……. [ A]Grand Multipara [B] Uterine Abnormalities[Bicorn ate septate uterus] [c] fibroid uterus [D]Contracted Pelvis ,Multiple pregnancy 2=FETAL FACTORS….. [A] Prematurity

9. Bicorn ate septate uterus Anencephaly

10. Cont.,,,,, [B] Macrosomia [ c ]Fetal Anomalies[Hydrocephalus , Anencephaly] [E] Twin pregnancy [F] Fetal death [G] Extended legs

11. CONT.,,, 3= PLACENTAL,AMNIOTIC FLUID FACTORS….. [A] Placenta P revia [B] oligohydramnios [C] Polyhydramnios [D] Nuchal cord [E] Short cord [F] Trisomy

12. Types,,,,, 1=COMPLETE BREECH PRESENTATION More common type 25% More common in multipara women Attitude= full flexion Thigh are flexed on the abdomen and the legs are flexed at the knees. The presenting part is buttocks and feet .

13. Cont.,,, B =INCOMPLETE BREECH PRESENTATION 1= FRANK BREECH Attitude flexed Thigh flexed on the trunk Legs Extended on the knee Joint. Presenting part Buttocks , External Genitalia . More common in primi =70%

14. Cont.,,, 2=FOOTLING BREECH[10-30%] Both the thigh and legs are partially extended bringing the legs to present at the brim. *Foot is the lower part . 3=KNEE PRESENTATION Thigh are extended but the knees are flexed ,bringing the knees down to the brim

15. position

16. DIAGNOSIS 1= CLINICAL A= ABDOMINAL PALPATION a= Fundal grip _ a smaller ,harder, more mobile , round , ballot able head can be felt in the fundus. B=lateral grip_ the back on one Side and limb on the opposite Side of the abdomen . aa

17. a c = pelvic grip Empty as soft irregular Buttocks do not engage Well like vertex.

18. Cont.,,,, B=AUSCULTATION Usually FHS heard above the level of the umbilicus . however in frank breech it may be heard at or below the level of the umbilicus. C= VAGINAL EXAMINATION

19. 2=Sonography 3=RADIOLOGY 4=HORMONAL TESTING

20. Mechanism of breech lie is longitudinal lie Attitude complete flexion Presentation breech Lt.sacro anterior position Denominator sacrum Presentig part anterior Buttocks [left]

21. Delivery of buttocks 1=Engagement 2=Decent 3= flexion 4=Internal rotation of buttocks 5=lateral flexion 5= crowing 6= Restitution 7=Delivery of buttocks

22. Delivery of shoulder 1=Engagement 2=Decent 3=Internal rotation 4=lateral flexion 5=Restitution 6=delivery of shoulder

23. Delivery of head 1=Engagement 2= Decent 3=Internal rotation 4= flexion 5= delivery of head

24. complication *Impacted breech Fetal hypoxia *Cord prolapse Intra cranial *Birth injuries hemorrhage * Erb s palsy Maternal trauma *Trauma Premature separation *Spinal cord damage of placenta

25. Management **ANTENATAL MANAGEMENT Identify complicating factors through sonography 1=EXTERNAL CEPHALIC VERSION = Manipulating process through change lie and make a favorable pole to the lower pole of uterus Steps=forward movement. Time =After 36 weeks.

26. External cephalic version

27. Cont … *Indication = breech presentation transverse lie *Advantages = spontaneous delivery reduce LSCS ,Reduce maternal and fetal mortality.

28. Cont…. Contraindication = Antepartum hemorrhage , fetal causes Multiple pregnancy , Ruptured membrane Contracted pelvic ,obstetric complication . Complication = Umbilical cord entanglement , placenta abruption Preterm labor , premature rupture of membranes

29. Cont . 2 =ELECTIVE CESAREAN SECTION In which the operation pre arranged time during pregnancy. INDICATION == Big baby , small baby , Fetal distress, hyperextended legs, footling presentation, IUGR

30. 3=vaginal breech delivery INDICATION = Average fetal weight flexed fetal head Adequate pelvic Without complication of medical, obg. MANAGEMET ACCORDING TO THE STAGE = FIRST STAGE = 1 Vaginal examination 2 check vital sign , FHS ,Empty bladder 3 IV Fluid start ,promote rest

31. Cont . 4= Maintain partograph . 5 =Assess fetal and progress of labor . 6 = Give adequate analgesic . *Morphine sulphate 10mg IM * pethidine hydrochloride 75-100 Mg IM * OTHER 50% Nitrous oxide +50% oxygen through inhalation.. 7=Reduce anxiety and fear of pain

32. Cont. SECOND STAGE = There are three methods of vaginal breech delivery : SPONTANEOUS (10%) Expulsion of fetus occurs with very little assistance. ASSISTED BREECH DELIVERY The delivery of fetus Is by assistance from the beginning to the end. These should be conducted by a skilled obstetrician.

33. steps *Positioning *Antiseptic cleaning *Encourage the patient bear down the expulsive force 1*Delivery of buttocks 2*Delivery of Arm = the assistant is to place a hand over the fundus and keep a steady pressure during uterine contraction to prevent extension of the arm . Soon, the anterior scapula is visible delivered the arm. 3*Delivery of head =this is the most crucial stage of the delivery The time between the delivery of umbilicus to mouth should preferably be 5-10 min.

34. A=BURns marshall method BABY: Allow to hang by its weight ASSISTANT : Downward , backward ,suprapubic pressure pressure to promote head flexion RIGHT HAND : Grasp ankle with a finger in between (when nape of neck is visible under pubic arch ) Trunk is swung upward ,forward till mouth is cleared off the vulva Depress the trunk to deliver the rest of hand LEFT HAND : Guard the perineum ,face ,brow.

35. 2 =FORCEPS DELIVERY OF HEAD BABY: Allow to hangs by its weight ASSISTANT : Give suprapubic pressure * raises legs of child when occiput is against pubic symphysis Piper forcep s is used . Head is delivered slowly (>1min.)to reduce compression and decompression.

36. 3=Modified mauriceau smellie-veit techinique BABY : Placed on supinated left hand with limbs hanging . ASSISTANT : Give suprapubic pressure . LEFT HAND : Middle and index fingers are placed on malar bones to maintain head flexion. RIGHT HAND : Ring , little finger on right shoulder. * index finger on left shoulder . * middle finger on suboccipital region. Downward ,backward traction is given till nape of neck is visible. Upward ,forward traction to release face and brow. Depressed to release occiput and vertex.

37. Breech extraction IT is rarely done these days as it produce trauma to the fetus and mother THIRD STAGE = The third stage is usually uneven full . The placenta is usually expelled out soon after delivery of the head . If Ergometrine is to be given ,it should be administered IV with crowning of the head .

38. MANAGEMENT OF THIRD STAGE EXPECTANT MANAGEMENT ACTIVE MANAGEMENT DELIVERY OF BABY CLAMP,DIVIDE, LIGATE THE CORD WAIT AND WATCH PLACENTA SEPRATED THROGH GRAVITY ASSISTED EXPULSION OF PLACENTA INJECTION OXYTOCIN 10 UNITS IM CLAMP ,DIVIDE ,LIGATE THE CORD DELIVERED PLACENTA BY CONTROLLED TRACTION WAIT FOR 10 MIN.,DELIVERD PLACENTA MANUAL REMOVAL METHARGINE 0.2Mg IM EXAMINE PLACENTA INSPECT VULVA ,VAGINA,PERINEUM

39. Fourth stage In the fourth stage perform strict supervision of both mother and baby . In which restore health of the mother. Prevent from infection . Emotional support Rest and ambulance Care of bowel and bladder Sleep Care of vulva, episiotomy wound * hospital stay Care of breast *maternal,infant bonding Diet * Asepsis and antiseptics Immunization

40. Special thanks for snehlata mam Lecturer of obg and gyne .