Breech Delivery

BREECH
PRESENTATION and DELIVERY
Sy, Icene Rose C.
JUNE 2013
buttocks of the fetus enter the pelvis before the head
Breech Presentation
3-4%
Breech Presentation
Factors predisposing to breech presentation

Gestational age Hydramnios high parity with uterine relaxation multiple fetuses Oligohydramnios Hydrocephaly Anencephaly previous breech delivery uterine anomalies placenta previa fundal placental implantation pelvic tumors
DIAGNOSIS
FRANK BREECH
COMPLETE BREECH
INCOMPLETE BREECH
Categories
ABDOMINAL EXAMINATION
L1 Hard, round, readily ballotable fetal head
L2 Back to be on one side of the abdomen and small parts on the other
L3 If not engaged, breech is movable above the pelvic inlet
L4 Firm breech to be beneath the symphisis
VAGINAL EXAMINATION
BREECH PRESENTATION
Anus, ischial tuberosities
FACE PRESENTATION
Mouth, malar prominence
Fingers encounter muscular resistance Firm, less yielding jaws with anus
Fingers maybe stained with meconium No stain on removal of fingers

Anus and ischial tuberosities lie in a straight line Mouth and malar prominence form a triangular shape
IMAGING TECHNIQUES
Sonography
Computed tomographic (CT) scanning Magnetic resonance (MR) imaging Radigraphic Pelvimetry
Can it be rectified to normal?
VERSION
External Cephalic Version

performed exclusively through the abdominal wall when a breech presentation is recognized prior to labor in a woman who has reached 36 weeks gestation Contraindications 1. Vaginal delivery is not an option 2. Placenta previa 3. Non-reassuring fetal status 4. Prior uterine incision (relative)
Complications Placental abruption, uterine rupture, hemorrhage, preterm labor
External Cephalic Version
A. Clockwise pressure is exerted against the fetal poles. B. Successful completion is noted by feeling the head above the symphysis during Leopold examination.
Mode of Breech Delivery
In 2000, researchers conducted a large, international multicenter randomized clinical trial comparing a policy of planned cesarean delivery with planned vaginal delivery (Term Breech Trial).
ACOG Committee Opinion July 2006
investigators noted that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower among the planned cesarean delivery group compared with the planned vaginal delivery group (17/1,039 [1.6%] versus 52/1,039 [5%]), although there was no difference in maternal morbidity or mortality observed between the groups
American College of Obstetricians and Gynecologists (ACOG) recommends that the decision regarding mode of delivery should depend on the experience of the health care provider.
Cesarean delivery is commonly, but not exclusively, used in the following circumstances:
Recommendations for Delivery
Techniques for Breech Delivery
Labor Induction & Augmentation

In oxytocin-augmented labor, however, infant mortality rates were higher and Apgar scores were lower. Cesarean delivery is preferred to oxytocin induction or augmentation with a viable fetus. Amniotomy induction is suitable.
Management of Labor
rapid assessment should be made to establish the status of the membranes, labor and fetal condition necessary staff
Methods of Vaginal Delivery

1. Spontaneous breech delivery.
without any traction or manipulation other than support of the newborn.
2. Partial breech extraction.

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.
3. Total breech extraction.

The entire body of the fetus is extracted by the obstetrician.
TOTAL BREECH EXTRACTION
Extraction of frank breech using fingers in groins.
Once the hips are delivered, each hip and knee is flexed to deliver them from the vagina.
TOTAL BREECH EXTRACTION
Frank breech decomposition using the Pinard maneuver. Two fingers are inserted along one extremity to the knee, which is then pushed away from the midline after spontaneous flexion. Traction is used to deliver a foot into the vagina.
DELIVERY OF THE ARMS
DELIVERY OF THE HEAD
MAURICEAU MANEUVER
A. flexion of the head is maintained by suprapubic pressure provided by an assistant. B. Pressure on the maxilla is applied simultaneously by the operator as upward and outward traction is exerted.
MODIFIED PRAGUE MANEUVER

Used when the back of the fetus fails to rotate to the anterior.
PIPER FORCEPS
A. The fetal body is held elevated using a warm towel and the left blade of forceps applied to the aftercoming head. B. The right blade is applied with the body still elevated. C. Forceps delivery of aftercoming head.
PIPER FORCEPS
A. The fetal body is held elevated using a warm towel and the left blade of forceps applied to the aftercoming head. B. The right blade is applied with the body still elevated. C. Forceps delivery of aftercoming head.
Entrapment of the Aftercoming Head

1. Dhrssen incisions. 2 oclock, 10 o'clock, 6 oclock.
2. Zavanelli maneuvercesarean delivery after replacement of the fetus back into the uterus.
3. Symphysiotomy - widen the anterior pelvis.
Analgesia and Anesthesia

Continuous epidural analgesia
Analgesia for episiotomy and intravaginal manipulations that are needed for breech extraction usually can be accomplished with pudendal block and local infiltration of the perineum. If general anesthesia is required, it can be induced quickly with thiopental plus a muscle relaxant and maintained with nitrous oxide.
Maternal Morbidity
Genital tract lacerations Intrauterine maneuvers Rupture of the uterus lacerations of the cervix and vaginal walls extensions of the episiotomy and deep perineal tears increase the risk of infection Anesthesia uterine atony postpartum hemorrhage
PROGNOSIS
Perinatal Morbidity & Mortality

Fetal injuries Fracture of humerus and clavicle Fracture of femur Neonatal perineal tears Upper extremity paralysis (eg pressure on brachial plexus) Term Breech Fetus head entrapment, cerebral injury and intracranial hemorrhage, cord prolapse, and intrapartum asphyxia
PROGNOSIS

Breech Delivery

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BREECH

PRESENTATION and DELIVERY

Sy, Icene Rose C.

buttocks of the fetus enter the pelvis before the head

Factors predisposing to breech presentation

L1 Hard, round, readily ballotable fetal head

L3 If not engaged, breech is movable above the pelvic inlet

L4 Firm breech to be beneath the symphisis

Fingers maybe stained with meconium No stain on removal of fingers

Can it be rectified to normal?

External Cephalic Version

Complications Placental abruption, uterine rupture, hemorrhage, preterm labor

External Cephalic Version

Mode of Breech Delivery

ACOG Committee Opinion July 2006

ACOG Committee Opinion July 2006

ACOG Committee Opinion July 2006

Recommendations for Delivery

Techniques for Breech Delivery

Labor Induction & Augmentation

Methods of Vaginal Delivery

2. Partial breech extraction.

3. Total breech extraction.

TOTAL BREECH EXTRACTION

Extraction of frank breech using fingers in groins.

TOTAL BREECH EXTRACTION

DELIVERY OF THE ARMS

DELIVERY OF THE HEAD

DELIVERY OF THE HEAD

MODIFIED PRAGUE MANEUVER

DELIVERY OF THE HEAD

DELIVERY OF THE HEAD

Entrapment of the Aftercoming Head

3. Symphysiotomy - widen the anterior pelvis.

Analgesia and Anesthesia

Perinatal Morbidity & Mortality

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