breech presentation vaginal delivery.pptx

Breech presentation, assisted breech delivery, breech extraction,mauriceau smelllie viet technique, Burns Marshall technique, forceps delivery in Breech,

1. CONDUCT OF vaginal DELIVERY IN BREECH PRESENTATION

2. Trial of Labor in Breech Criteria: Frank or complete breech Term gestational age 36 to 42 weeks Estimated fetal weight 2500 to 3500 grams Adequate maternal pelvis No maternal or fetal indication for a cesarian section

3. Management of First stage of labor Bed rest Foetal heart rate monitoring for every 15 minutes especially after rupture of membranes. Vaginal examination after rupture of membranes. Labour is allowed to continue provided there is no cord prolapse

4. Spontaneous breech delivery: The fetus is expelled spontaneously without any MANIPULATION OTHER THAN SUPPORT OF THE NEWBORN. Most common during the delivery of a dead foetus. Accounts for only 10% of total breech deliveries done.

5. ASSISTED BREECH DELIVERY: The foetus is delivered spontaneously upto the level of umbilicus but the remainder of the body is delivered with assistance. Consists of three P’s: P- Prerequisites P- Principles P- Procedure

6. PREREQUISITES: Skilled obstetrician Anaesthetist An Assistant Instruments and suture materials for episiotomy A pair of obstetric forceps Appliances for the resuscitation of the baby A Neonatologist

7. PRINCIPLES: Never to rush. Never to pull but to push from above. Always keep the back of the baby anteriorly.

8. PROCEDURE: Preparations Delivery of the breech Delivery of the shoulders Delivery of the after coming head

9. PREPARATIONS: Patient is brought to bed when anterior buttock and the anus are visible. Keep in left lateral position. Place her in lithotomy position when the posterior buttock distends the perineum Antiseptic cleaning Catheterisation of bladder Local infiltration anaesthesia- 10ml of 1% lignocaine

10. DELIVERY OF BREECH: EPISIOTOMY: It is given when the “climbing of the breech” occurs Patient is asked to bear down. No touch to the foetus policy is strictly followed. If there is any difficulty groin traction is given. Umbilical cord is pulled down to one side of the sacrum to avoid cord compression. After the delivery of the umbilicus if the back is posterior rotate it to anterior.

11. DELIVERY OF shoulders: What to look? Position of the scapula – Parallel or winging interpretation – Parallel – Flexed arms Winging – Extended arms What to do? (flexed arms) The shoulders are to be delivered one after the other only when one axilla is visible. Delivery is simply done by hooking out each arm at the elbow

12. DELIVERY OF THE POSTERIOR shoulder:

13. DELIVERY OF THE ANTERIOR shoulder:

14. DELIVERY OF THE AFTER COMING HEAD: Crucial part of breech delivery. The interval between the delivery of the umbilicus to the delivery of the head should be 5 – 10 minutes. Methods to deliver the after coming head Mauriceau smellie veit technique (modified) Burns-Marshall method Forceps delivery

15. MODIFIED MAURICEAU-SMELLIE-VEIT TECHNIQUE Baby is placed over the supinated left fore arm with limbs hanging on each side The index and middle finger of the left hand are placed over the malar eminences of the baby This maintains the flexion of the head The ring and little fingers of the pronated right hand are placed on the baby’s right shoulder And index finger is kept over left shoulder Middle finger is placed on the sub occipital region traction is given in downward and backward direction till the nape of the neck is visible under the pubic arch Suprapubic pressure is given by the assistant The foetus is carried upward and forward position towards the mothers abdomen to release the face and the trunk is depressed to release the occiput

16. MODIFIED MAURICEAU-SMELLIE-VEIT TECHNIQUE

17. BURNS-MARSHALL METHOD: Baby is allowed to hang on its own weight The assistant is asked to give suprapubic pressure with a flat hand in a downward and backward direction This is to promote the flexion of the head When the nape of the neck is visible under pubic arch Ankles of the baby are grasped with a finger in between Maintaining a steady traction a wide arc of a circle is formed by swinging the trunk upward and forward direction Left hand is placed over the perineum to successively slip off from the face of the baby

18. FORCEPS DELIVERY: The head should be brought as low down as possible When the occiput lies against the back of the pubic arch The assistant raises the legs of the baby to facilitate the introduction of forceps from below The head should be delivered slowly to avoid decompression and compression of the head which may cause intracranial bleeding

19. ADVANTAGES: Delivery can be controlled by giving pull directly on the head not through neck Adequate flexion of the head is always ensured Mucus can be sucked out from the mouth more effectively

20. Total breech extraction Rarely done these days One of the few indications where it may be followed are, delivery of second twin after ipv and delivery of extended legs arrested at the cavity or outlet. A Hand is introduced through the vagina and both feet of the fetus are grasped With gentle traction, the feet are brought through the interoitus . The traction is continued and successive parts are grasped and extracted until the buttocks emerge and the body rotates anteriorly. The remaining steps are completed as it is done for assisted breech delivery.