Professional Documents
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31
31
and Delivery
Tanitra Tantitamit
22 May 2007
Breech presentation
The incidence is highly dependent on the gestational age.
At 20 weeks‘ about ¼ preganacies, By full term, the incidence is about 4%.
Etiology
Etiology
Factors that appear to predisposes to breech presentation
Hydramnios
Uterine relaxation associate with great parity
Multiple fetus
Hydrocephalus
Anencephaly
Previous breech delivery
Uterine abnormalities
Pelvic tumor
Placenta implantation at cornual-fundal region
Complications
Complications
• Abdominal examination
– Hard round and ballotable fetal head is found to
occupy the fundus
– The breech is movable in pelvic inlet
(no engagement) or beneath pelvic symphysis
(engagement)
– FHS heard loudest above the umbilicus
Diagnosis
• Vaginal examination
– Frank breech
• Both ischial tuberrosities sacrum and anus are palpable
• The mouth and malar eminence form triangular shape
whereas the ischial tuberosities and anus are in straight line
– Complete breech
• Feet may be felt alongside the buttock
– Incomplete breech
• One or both feet are inferior to the buttock
Diagnosis
• Imaging technique
– Ultrasound
• Confirm a clinically suspected
breech presentation and
fetal anomalies
• If vaginal delivery is considered
– Type of breech presentation
– Degree of flexion or deflexion of head
Diagnosis
• Imaging technique
– CT scan
• Provide pelvic measurement and configuration
at lowest dose of radiation
– MRI
• Provide reliable pelvic capacity and architecture without
ionizing radiation but not available
– X-RAY
• Varies among study, there was no correlation between pelvic
measurement and labor outcome
Prognosis
Prognosis
• Maternal morbidity
– Because of the higher risk of cesarean delivery,there is higher
maternal morbidity and slightly higher mortality
• Hyperextension
– Present in 5% of breech presentation, result in injury
of cervical spinal cord and considered an indication
of cesarean section
Vaginal delivery
• Labor induction and augmentation
– Defended by some clinicians and condemned by others
• Footling breech
– Possibility of compression of a prolapsed cord or cord entangled
around the extremities is threat fetus
Vaginal delivery
• Recommendation for cesarean delivery
– A large fetus
– Any degree of contraction or unfavorable shape of pelvis
– Hyperextended head
– When delivery is indicated in the absence spontaneous labor
(some clinician used oxytocin)
– Uterine dysfunction (some clinician used oxytocin)
Vaginal delivery
• Recommendation for cesarean delivery
– Footling breech
– Healthy ,viable preterm fetus with mother in active labor
– Severe IUGR
– Previous perinatal death
– Request for sterilization
– Lack of an experienced operator
Technique for breech delivery
Mechanism of labor
• Engagement and descend of breech
– Bitrochanteric diameter
in oblique pelvic diameter
• Internal rotation 45° of breech
– Bitrochanteric diameter
in anteroposterior pelvic diameter
• Lateral flexion of body
– Forced by perineal floor
• External rotation of breech
and internal rotation of shoulder
– Biacromian and bitrochanteric in AP diameter
• Flexion of head upon the thorax then rotates in a such manner as
to bring the posterior of neck under pubic symphysis
Methods of vaginal delivery
• Spontaneous breech delivery
– Without traction or manipulation other than support infant
• Partial breech extraction
– Delivered spontaneously as far as the umbilicus.
– Body is extracted with operator traction and assisted maneuver
• Total breech extraction
– The entire body of the infant is extracted by the obstetrician
Management of labor
• Rapid assessment the status of labor
– Satisfactory progress in labor was the best indicator of pelvic adequacy
– Close surveillance FHR and UC
Prague maneuver
Consists of two fingers of one
hand grasping the shoulders
of the back-down fetus from
below while the other hand
draws the feet up over
maternal abdomen
Delivery of the aftercoming head
IV nitroglycerin
Not compelling evidence
Zavanelli maneuver
C/S after replacement of infant into uterus
Symphysiotomy
rare use, serious maternal injury
Frank breech extraction
Moderate traction exerted by finger in
each groin and facilitated by generous
episiotomy
Pinard maneuver
Two fingers are inserted along one extremity to
the knee , then pushed away from midline after
spontaneous flexion to deliver a foot into vagina
Morbidity and Mortality
Maternal injuries
Increase risk of infection
caused by manual manipulation within birth canal
Rupture of uterus and cervical laceration
Intrauterine maneuver ,delivery of aftercoming head
through an incompletely dilate cervix
Deep perineal tear
Extension of episiotomy
Fetal injuries
Fracture humerous and clavicle
Fracture femur
Hematoma of sternocliedomastoid muscle,
usually disappear spontaneously
Brachial plexus injuries (Paralyse arm)
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