PGI Dolendo, Vanessa

Breech: Buttocks of the fetus enter the pelvis before the head. Britches, which described a cloth covering the loins and thighs. About 3 to 4 percent of singleton deliveries. Before the onset of labor the fetus turns spontaneously to a cephalic presentation

Gestational age Hydramnios Uterine relaxation associated with great parity, multiple fetuses Oligohydramnios Hydrocephaly Anencephaly Previous breech delivery Uterine anomalies Pelvic tumors

The lower extremities are flexed at the hips and extended at the knees, and thus the feet lie in close proximity to the head.

Differs in that one or both knees are flexed.

One or both hips are not flexed and one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal. Footling breech is an incomplete breech with one or both feet below the breech.

The sacrum is the denominator of breech and there are 6 positions: a)Right sacro posterior b)Left sacro posterior c)Right sacro lateral d)Left sacro lateral e)Right sacro anterior f)Left sacro anterior The commonest position is assumed at left sacro anterior.

Left sacrum anterior (LSA)the buttocks, as against the occiput of the vertex presentation, like close to the vagina (hence known as breech presentation), which like anteriorly and towards the left. Right sacrum anterior (RSA)the buttocks face anteriorly and towards the right. Left sacrum posterior (LSP)the buttocks face posteriorly and towards the left. Right sacrum posterior (RSP)the buttocks face posteriorly and towards right. Sacrum anterior(SA)the buttocks face anteriorly. Sacrum posterior (SP)the buttocks face posteriorly.

Leopold maneuvers First : the hard, round, readily ballotable fetal head is found to occupy the fundus. Second : indicates the back to be on one side of the abdomen and the small parts on the other. Third: if engagement has not occurredthe intertrochanteric diameter of the fetal pelvis has not passed through the pelvic inletthe breech is movable above the pelvic inlet. Fourth: shows the firm breech to be beneath the symphysis.
Fetal heart sounds usually are heard loudest slightly above the umbilicus, whereas with engagement of the fetal head, the heart sounds are loudest below the umbilicus.

Frank breech presentation:

both ischial tuberosities, the sacrum, and the anus usually are palpable, and after further descent, the external genitalia may be distinguished. During prolonged labor, the buttocks may become markedly swollen, rendering differentiation of face and breech very difficultthe anus may be mistaken for the mouth and the ischial tuberosities for the malar eminences.

Complete breech presentations:

the feet may be felt alongside the buttocks, and in footling presentations, one or both feet are inferior to the buttocks.

Footling presentations:

the foot can readily be identified as right or left on the basis of the relation to the great toe. When the breech has descended farther into the pelvic cavity, the genitalia may be felt.

 VD         Frank position GA>34w FW=2000-3500gr Adequate pelvis Flexed head Nonviable fetus No contraindication Good progress labor

CS          FW> 3500gr Footling Small pelvis Deflexed head Arrest of labor GA24-34w Elderly PG Inf or poor history Fetal distress

Spontaneous breech delivery.

The infant is expelled entirely spontaneously without any traction or manipulation other than support of the infant.

Partial breech extraction.

The infant 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.

Total breech extraction.

The entire body of the infant is extracted by the obstetrician.

Stage of Labor Fetal Condition Fetal Monitoring Route of delivery Timing of Delivery

Frank breech should ideally be allowed to deliver without assistance to at least the level of the umbilicus. The breech progressively distends the perineum, the posterior hip will deliver, usually from the 6 o'clock position, and often with sufficient pressure to evoke passage of thick meconium at this point.

The anterior hip then delivers, followed by external rotation to the sacrum anterior position.

The fingers should rest on the anterior superior iliac crests and the thumbs on the sacrum, minimizing the chance of fetal abdominal soft tissue injury

Maternal expulsive efforts are used in conjunction with continued gentle downward operator rotational traction to effect delivery of the fetus.

Gentle downward traction is combined with an initial 90-degree rotation of the fetal pelvis through one arc and then a 180-degree rotation to the other to effect delivery of the scapulas and arms

Extraction of a frank breech may be required and can be accomplished by moderate traction exerted by a finger in each groin and facilitated by a generous episiotomy

Two fingers are carried up along one extremity to the knee to push it away from the midline. Spontaneous flexion usually follows, and the foot of the fetus is felt to impinge on the back of the hand. The fetal foot then may be grasped and brought down.

During total extraction of a complete or incomplete breech, the hand is introduced through the vagina and both feet of the fetus are grasped. The ankles are held with the second finger lying between them and, with gentle traction, the feet are brought through the vulva.

As the legs begin to emerge through the vulva, downward gentle traction is then continued. As the legs emerge, successively higher portions are grasped, first the calves and then the thighs

A cardinal rule in successful breech extraction is to employ steady, gentle, downward rotational traction until the lower halves of the scapulas are delivered outside the vulva, making no attempt at delivery of the shoulders and arms until one axilla becomes visible.

Leverage is exerted on the posterior shoulder, which slides out over the perineal margin, usually followed by the arm and hand.

By depressing the body of the fetus, the anterior shoulder emerges beneath the pubic arch, and the arm and hand usually follow spontaneously.

If the nuchal arm cannot be freed in the manner described, extraction may be facilitated, especially with a single nuchal arm, by rotating the fetus through half a circle in such a direction that the friction exerted by the birth canal will serve to draw the elbow toward the face.

Mauriceau Maneuver The index and middle finger of one hand are applied over the maxilla, to flex the head, while the fetal body rests on the palm of the hand and forearm
It is emphasized that with this maneuver, the operator uses both hands simultaneously and in tandem to exert continuous downward gentle traction simultaneously on the fetal neck and on the maxilla.

Prague Maneuver The back of the fetus fails to rotate to the anterior. When this occurs, rotation of the back to the anterior may be achieved by using stronger traction on the fetal legs or bony pelvis.
If the back still remains oriented posteriorly, extraction may be accomplished using the Mauriceau maneuver and delivering the fetus back down. If this is impossible, the fetus still may be delivered using the modified Prague maneuver, which, as practiced today, 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 the maternal abdomen

Piper forceps Laufe forceps

Applied electively or when the Mauriceau maneuver cannot be accomplished easily.

The blades of the forceps should not be applied to the aftercoming head until it has been brought into the pelvis by gentle traction, combined with suprapubic pressure, and is engaged. Suspension of the body of the fetus in a towel effectively holds the fetus and helps keep the arms out of the way.

A procedure in which the fetal presentation is altered by physical manipulation, either substituting one pole of a longitudinal presentation for the other or converting an oblique or transverse lie into a longitudinal presentation.

Recommendations: External Cephalic version (ECV): uncomplicated breech presentation in the 36th week age og gestation. Cesarean section is recommended if ECV failed (term, singleton breech presentations)- it decreases perinatal mortality and neonatal morbidity. CS is preferred mode of delivery because of diminishing expertise in vaginal delivery

At Tern, reduced the number of non vertex births. Complications: Fetal heart rate abnormalities- TRANSIENT BRADYCARDIA- most common Abruptio placenta Painless vaginal bleeding Admission for induction of labor