ASSISTED BREECH DELIVERY

Dr. Swati singh

Department of Obs. & Gyn.

UDUTH SOKOTO NIGERIA

• Introduction• Incidence• Types• Aetiology• Management of vaginal breech delivery• Criteria for assisted breech delivery• Principles of assisted breech delivery• Steps in assisted breech delivery• Complication• Conclusion

Outline

Introduction

• The subject of breech presentation especially the aspect of breech deliveries has always evoked intense interest among obstetricians.

• The term breech was derived from the word ‘Britches’ which is a cloth used to cover the loins and thighs.

• Breech presentation therefore occurs when the fetal pelvis or lower extremities present in the maternal pelvis.

• Breech delivery is a major issue in obstetric practice because of the attendant high fetal morbidity and mortality.

Incidence• Breech is most common

malpresentation in pregnancy• The incidence of breech varies with

gestational age• It is 30%-40% at 20-25 weeks of

gestation• 25% at 28-30 weeks• 15% at 32 weeks• 2% - 3% at term• 2.6% in Ibadan by Fawale.et. al,2001• 2.4% in Ile-Ife by Shittu et. al 2001.• UDUTH it was 2.4% (Tunau K 2007 part

2 book).

Types• Frank or extended breech: 65%

cases• Complete or flexed or full breech:

10%• Footling breech or incomplete

breech:

Aetiology• Cause is unknown but any

fetomaternal condition which prevent the spontaneous version will result in a breech presentation

• Fetal – Prematurity – It is the commonest cause– Multiple pregnancy– Fetal abnormalities e.g. hydrocephalus,

anencephaly, neck masses & aneuploidy

Aetiology

• Maternal– Multiparity– Polyhydramnios or oligohydramnios– Pelvic tumours– Congenital uterine anomalies e.g.

bicornuate or septate uterus

• Placental– Placenta praevia– Cornual implantation of placenta

Management option of breech delivery

• External cephalic version• Elective CS• Assisted breech delivery

Criteria for vaginal breech delivery• No feto-pelvic disproportion pelvis

must be adequate• No maternal complicating factors like-

Heart ds. Severe pre-eclampsia, abruptio and precious pregnancy

• Estimated fetal wt. < 3.5kg• Favorable fetal attitude eg. Frank

breech• Availability of an experienced

obstetrician, An assistant, Anaesthesiologist & paediatrician

Management of vaginal breech delivery First stage

• Vaginal exam. is indicated– At the onset of labour for pelvic

assessment– Soon after rupture of membrane to

exclude cord prolapse

• An intravenous line should be established

• Adequate analgesia • Fetal status and progress of labour are

monitored

Management of 2nd stage

• There are 3 methods of vaginal breech delivery– Spontaneous – Assisted breech delivery– Breech extraction

Principles of assisted breech delivery

• Don’t rush: aggressive and hasty pull may cause entrapment of after coming head through the incompletely dilated cervix

• Always keep the fetus with the back anteriorly

• Delivery of after coming head (don’t pull from below but suprapubic pressure can be applied)

Steps in assisted breech delivery

• Patient is transferred to the delivery couch when in 2nd stage.

• Antiseptic cleaning is done, bladder is emptied.

• She is placed in lithotomy position when the post. Buttock distend the perineum

• Pudendal block and episiotomy is given when climbing the perineum

Steps in assisted breech delivery

• Patient is encourage to bear down with each uterine contraction.

• The ‘no touch of the fetus’ policy is adapted until the buttock are delivered along with the legs in flexed breech & the trunk slips up to the umbilicus

Steps in assisted breech delivery

• When the trunk has been delivered upto the level of the umbilicus.– The extended legs in frank

breech are to be delivered by the pressure on the knees (popliteal fossa) in the manner of abduction and the flexion of the thighs. Further flexion can be obtained by gradually reaching for the ankle, grasped and eased out the foot.

Steps in assisted breech delivery

• Umbilical cord is then freed to avoid tension on it

• The baby is wrapped with a sterile towel to prevent slipping when held by the hands and to facilitate manipulation, if required

• Delivery of the arm– A steady traction is applied

at the hips till the ant. Scapula is visible, the position of the arm should be noted

– The Flexed arm delivered one after the other by simply hooking down elbow with a finger across the face

Steps in assisted breech delivery

Delivery of the arm

• Extended arm– If the arms are

extended adduction and flexion of the shoulder followed by extension at the elbow helps to bring down the forearm and hand.

– ‘Lovset maneuver’

Delivery of the arm• ‘Lovset maneuver’ is resorted

to where the posterior shoulder, which is below the level of the sacral promontory, is brought anterior below the symphysis pubis by rotating the fetus clockwise by holding the baby with the thumbs on the sacrum and index fingers on the anterior superior iliac spines. After delivery of the shoulder which has come anterior the fetus is turned in the anticlockwise direction to enable descent of the opposite shoulder. The arm is then delivered

Delivery of the after coming head

• This is the most crucial stage of the delivery

• The time between delivery of the umbilicus to delivery of mouth should preferably be 5 – 10 min.

• Various methods of delivery.– Mauriceau-smellie-veit maneuvre– Burn-Marshall method– Forceps delivery

Mauriceau-Smellie-Viet maneuver

• A Mauriceau-Smellie-Viet maneuver follows. The fetus is placed abdomen down on the operator's right arm. The left hand supports the fetal neck. The index and middle fingers of the right hand are placed on the fetal maxilla to help maintain flexion of the head. The assistant may apply suprapubic pressure to deliver the after-coming head

Burn-Marshall method• The procedure here is to gently sweep the

baby’s limbs and truck over the mother’s abdomen

• By holding both legs and applying traction downwards & upwards with the back of the baby’s trunk & limbs sweeping an arc over the mother’s abdomen, the fetal mouth and nostrils are brought in view.

• These orifices are suctioned to clear airways of fluid and the remaining part of the head is delivered

Forceps delivery • Forceps may

be used to facilitate delivery of the after-coming head. Maintenance of head flexion is crucial. Traction is not required.

•Use of forceps may be helpful in a nulligravida or when the fetus is small and at term (less than 2500 g).•The Piper forceps and Elliott forceps are specially designed for this task. Because the fetal head is visible and should be aligned as in an occiput anterior position.

Complication

• Maternal– Increase frequency of operative

delivery including CS, the morbidity is increased

– The risk of trauma to genital tract, episiotomy, forceps, haemorrhage and infection. causes maternal morbidity and mortality

Complication• Fetal

– Prematurity– Dislocation of the jaw and the joint– Birth asphyxia

• Cord compression and cord prolapse• Prolong labour• Entrapment of after coming head

– Intracranial hemorrhage– Injury to the abdominal organ– Fracture of the bones (humerus, clavicle, femur and neck)

– Nerve injuries ( cervical plexus, brachial plexus, spinal cord)

Conclusion

• Breech presentation at any gestational age is associated with a higher perinatal morbidity and mortality than vertex presentation irrespective of mode of delivery

• It is with a view to minimizing this high perinatal morbidity and mortality that the knowledge and skill of assisted breech delivery are highly desirable.