Breech presentation obstetrics .pptx

Breech presentation and types

1. BREECH

2. BREECH PRESENTATION Defined as longitudinal lie with variation in polarity. Denominator – Sacrum Engaging diameter – Bitrochanteric diameter Frequency: depends on period of gestation at 32 weeks: 16% at term : 3-5%

3. COMPLETE BREECH Fetus maintains the attitude of universal flexion with the thighs flexed at hips and the legs at the knees.

4. INCOMPLETE FRANK BREECH FOOTLING KNEELING

5. CLINICAL VARIETIES UNCOMPLICATED COMPLICATED No other associated obstetric complications apart from breech. Conditions associated which adversely influence the prognosis. Eg : prematurity twins placenta previa contracted pelvis

6. ETIOLOGY: MATERNAL FACTORS FETAL FACTORS PLACENTAL FACTORS Uterine relaxation associated with high parity Multiple pregnancy Placenta previs Oligohydramnios Hydrocephaly , Anencephaly Placenta in cornual fundal region Polyhydramnios Chromosomal anomalies Uterine anomalies IUD Neoplasms such as leiomyomata Contracted pelvis

7. Diagnosis of Breech- clinically

8. Ultrasonography: Confirms the clinical diagnosis. Detect congenital anomalies Type of breech Measures BPD, GA, EFW Localises placenta Assessment of Liquor Attitude of the Head

9. Positions:

10. Mechanism Of Labour 3 stages Delivery of buttocks & lower limbs Delivery of the shoulders & arms Delivery of the Head

11. Mechanism of Labour in Sacro anterior position

12. Delivery of buttocks & lowerlimbs ENGAGEMENT DESCENT & INT. ROTATION BREECH CLIMBING BIRTH OF POST. BUTTOCK BIRTH OF ANT. BUTTOCK

13. Delivery of the shoulders & arms Feet is born & shoulders engaging. Descent & internal rotation of shoulders Posterior shoulder born; head has entered the pelvis

14. Delivery of the Head Anterior shoulder born, descent of head. Internal rotation & flexion of head Flexion of the head complete

15. Prognosis MATERNAL FETAL In spontaneous delivery - maternal prognosis is good. Genital tract lacerations Hemorrhage Perinatal mortality 9-25% Perinatal deaths 3-5 times higher than non breech deliveries Fetal mortality least in frank breech and maximum in footling presentation Factor influencing fetal risk: Skill of obstetrician Weight of baby Leg’s position Type of pelvis

16. FETAL DANGERS Birth asphyxia Birth injuries Injury to brain and skull : (a) Intracranial hemorrhage (b) Minute hemorrhages, (c) Fracture of the skull Hematoma - sternomastoid/ thighs Fracture – femur, humerus, clavicle, odontoid process Visceral injuries - liver/ kidney / lungs rupture Nerve – Erb’s / Klumpke’s palsy Long-term neurological damage Intrapartum fetal death

17. Prevention of fetal hazards Minimize breech incidence by ECV Delivery by cesarean section Vaginal breech delivery by skilled obstetrician, anesthesist , neonatologist

18. MANAGEMENT Antenatal period: if breech presentation is found to persist in a primigravida after 34 weeks- attempt to find etiological cause. If no etiological factor is found: ECV Upto 34 weeks, breech presentation is common and many correct themselves spontaneously by 34 weeks. After 36 weeks it is rare for spontaneous correction to occur. In 60% of breech presentation- version can be successfully attempted.

19. ECV To bring the cephalic pole in the lower pole of the uterus Timing- From 36 weeks. Early: chance of reversion late: ↑ size of the fetus ,↓ liquor Benefits: ↓ incidence of breech at term, ↓ incidence of breech delivery, ↓ incidence of C- Section. Successful in Failure in Complete breech Breech with extended legs Non engaged breech Short cord Sacro anterior position Uterine m alformations Adequate liquor Scanty liquor/ big baby Non obese patient Obesity

20. PREREQUISITES Singleton pregnancy No contraindication to labor and vaginal delivery Normal fetal well-being Normal amniotic fluid Position confirmed before ECV Facilities available for immediate cesarean section CONTRAINDICATIONS Any contraindication to labor Antepartum hemorrhage Some major fetal anomalies Multiple gestation Ruptured membranes Oligohydramnios Hyperextension of the fetal head Morbid obesity Active labor Uterine anomalies Prev. C- Section

21. ECV PROCEDURE USG – confirm diagnosis and adequate liquor A reactive NST Empty bladder Position of patient: supine with shoulders slightly raised, thighs slightly flexed and abdomen fully exposed Fetal presentation, position of back and limbs are checked FHR auscultated

22. ‘Forward Roll’ Movement Step 1 Mobilize breech using both hands towards which back of fetus lie Right hand : grasp podalic pole Left hand: grasp head STEP-2 L:Pressure exerted to head to push breech R:Pressure in opposite direction to guide vertex Intermittent pressure given till lie become transverse FHR is checked Changing of hands Intermittent pressure exerted till head is brought to lower pole of uterus STEP-3 :Changing of hands Intermittent pressure exerted till head is at lower pole of uterus.

23. Reactive NST should be obtained Undue bradycardia ( head compression) is settled down by 10 minutes If persist, cord entanglement may occur and reversion is done. Patient is observed for 30 minutes to : Allow FHR to settle down Note any vaginal bleeding/ sign of PROM Patient is advised for follow-up, to report any vaginal bleeding/leakage and Rh-negative woman is given 100µg anti-D IG.

24. Dangers of version Immunoprophylaxis with Anti-D in Rh negative mother. A reactive CTG trace should be obtained after the procedure DANGERS Premature onset of labour PROM Placental abruption & bleeding Entanglement of cord –true knot- causing impairment of fetal circulation & finally death ↑ feto maternal bleed Amniotic fluid embolism.

25. If version fails or is contraindicated; 2 methods of delivery can be planned : 1. To perform an elective cesarean section 2. To allow spontaneous labor to start and vaginal breech delivery to occur.

26. Indications for C- section Indications Large fetus , EFW>3.5kg IUGR Placenta previa of any degree Any degree of pelvic contraction Hyperextended head Footling presentation Previous perinatal death/ H/O birth trauma Need to terminate pregnancy- fetal / maternal indication Placental insufficiency Failure of descent of breech Cord prolapse

27. Zatuchni -Andros Breech Scoring If the score is 0-4, cesarean delivery is recommended 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

28. VAGINAL DELIVERY Spontaneous breech delivery Assisted breech delivery Total breech extraction

29. MANAGEMENT OF THE FIRST STAGE Rest in bed - due to fear of cord prolapse in the event of rupture of membranes FHR should be observed atleast every 15 minutes . Especially after ROM. With increasing uterine contraction, breech begins to descend. An IV line is started with RL When membranes rupture advisable to conduct a vaginal examination.

30. MANAGEMENT OF SECOND STAGE Depending on the level of assistance required Spontaneous (10%): not preferred Usually with very LBW & dead babies Assisted breech : The fetus is delivered spontaneously as far as the umbilicus, but the remainder of the body is extracted or delivered with operator traction and assisted maneuvers, with or without maternal expulsive efforts. Breech extraction : entire body of fetus is extracted by obstetrician Indications: delivery of 2 nd twin after IPV Cord prolapse Extended legs

31. ASSISTED BREECH DELIVERY

32. NEED FOR PLANNING Before starting to assist the breech delivery, all arrangements must be ready to treat neonatal asphyxia. No necessity to hurry and complete the delivery. episiotomy is given when between contractions the baby’s anus is visible at the vulval outlet- CLIMBING ON THE PERINEUM Golden rule in assisted breech delivery : Keep the hands off the breech and allow the breech to deliver spontaneously till the umbilicus.

33. Delivery of breech The patient is encouraged to bear down with the contractions but must rest between them As long as there is no fetal or maternal distress, spontaneous delivery to the umbilicus is awaited. The legs usually deliver spontaneously; if not they are easily extracted. Do not extract the legs until the popliteal fossae are visible ( Pinard’s maneuver) The baby is covered with a warm towel, and the body is supported A loop of umbilical cord is pulled aside.

34. Pinard’s maneuver : Index & middle fingers guided along the posterior aspect of the thigh to the knee and gentle pressure exerted at the popliteal fossa . Causes the leg to flex at the knee. The foot is then grasped and foot brought down to the vulva.

35. Delivery of shoulders

36. Loveset’s maneuver: Baby is grasped using both hands at femoro pelvic grip & thumbs parallel to vertebral column. Should start only after inferior angle of anteror scapula is visible underneath pubic arch.

37. Delivery of the After Coming Head Time gap between delivery of umbilicus and mouth: 5 – 10 minutes Methods: Burns- Marshall method Modified Mauriceau - Smellie - Veit technique Wigand Martin Maneuver Forceps delivery

38. BURNS MARSHALL METHOD Baby : allowed to hang by its weight Assistant : downward, backward suprapubic pressure Aim : to promote flexion of head Right hand : grasp ankles 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 head Left hand : guard the perineum

39. FORCEPS DELIVERY Baby: allow to hang by its weight Assistant: give suprapubic pressure raises legs of child when occiput is against pubic symphysis Piper forceps is used Head is delivered slowly (over 1 min) to reduce compression-decompression

40. Modified Mauriceau - Smellie - Veit technique malar flexion and shoulder traction 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 and little fingers on right shoulder Index finger on left shoulder Middle finger on sub-occipital 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 verte x

41. Wigand martin maneuver The body of the baby is placed on the arm of the operator with the middle finger of the hand of that arm placed in the baby’s mouth and the index and ring fingers on the malar bones Maintain flexion. With the other hand, the obstetrician exerts suprapubic pressure on the head through the mother’s abdomen

42. COMPLICATIONS Premature rupture of membranes and imperfect dilatation of cervix. Head entrapment Prolapse of cord Extended arms Difficulty in after coming head

43. PREMATURE RUPTURE OF MEMBRANES AND IMPERFECT DILATATION OF THE CERVIX VERY COMMON More common in footling & complete breech Foot slips out in a fully flexed breech presentation. No attempt should be made to extract the breech, when the cervix is not fully dilated- tears of the cervix, difficulties in delivering the arm and head- stillbirth . Better deliver by C- section.

44. HEAD ENTRAPMENT Most feared -through an incompletely dilated cervix. Commonly occurs with preterm breech vaginal delivery. Cord gets compressed by the cervix gripping the head. Rapid delivery is necessary. If the cervix is rigid and unyielding: DUHRSSEN INCISION is given at 2 o’clock and 10’oclock

45. PROLAPSE OF THE CORD Common in complete breech, more common in footling presentation. Immediate C- section If completely dilated cervix- BREECH EXTRACTION

46. EXTENDED ARMS Can be due to undue traction from below or due to delivery from an incompletely dilated cervix. Lovset’s maneuver If this fails: Baby should be held up to one side by its feet and a hand passed into vagina. Passes into the hollow of the sacrum along the side of the baby’s arm. It should never be brought across the back- causes fracture of the humerus . Once posterior arm is delivered, anterior arm is delivered. Should there be difficulty, baby rotated so that the anterior arm is made posterior.

47. DIFFICULTY IN AFTERCOMING HEAD Deflexion of the head Undiagnosed disproportion between the head and the pelvic brim Delivery through an imperfectly dilated and retracted cervix. Narrow subpubic arch.

48. EXTENDED BREECH Best fetal prognosis Assistance may be required in delivery of the legs. Pinard’s maneuver : Introduce gloved hand into the vagina, fingers guided along the posterior aspect of the thigh to the knee and gentle pressure exerted at the popliteal fossa. Causes the leg to flex at the knee when the fingers are passed along the shin till it reaches the foot. The foot is then grasped and foot brought down to the vulva.

49. Occipito -posterior head Usually in spontaneous breech delivery Grasp fetal trunk and head with hands positioned like that in malar flexion and shoulder traction, then rotate to bring them anteriorly In premature baby, (Prague Maneuver )-head is delivered face to pubis by reverse malar flexion and shoulder traction Forceps Prague Maneuver

50. IMPACTED BREECH Occurs with extended breech Causes: Disproportion between the size of the breech and the pelvis In the cavity- alterations in the capacity of pelvis & also the shape Android pelvis Thorough antenatal assessment- if diagnosed C-section should be attempted. At cavity: with baby in good condition deliver by C- section. At the outlet: episiotomy and traction with a finger in the groin.

51. PROGNOSIS MATERNAL Increased operative delivery Increased genital tract trauma,sepsis , anesthetic complications Increased morbidity FETAL Perinatal mortality 9-25% Perinatal deaths 3-5 times higher than non breech deliveries Fetal mortality least in frank breech and maximum in footling presentation Factor influencing fetal risk: Skill of obstetrician Weight of baby Leg’s position Type of pelvis

52. THANK YOU