Breech Delivery Technique

8/3/2019 Breech Delivery Technique

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PGI Dolendo, Vanessa


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Breech: Buttocks of the fetus enter the pelvisbefore the head.

Britches,which described a cloth covering theloins and thighs.

About 3 to 4 percent of singleton deliveries.

Before the onset of labor the fetus turnsspontaneously to a cephalic presentation


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Gestational age

Hydramnios

Uterine relaxation associatedwith great parity,

multiple fetuses Oligohydramnios

Hydrocephaly

Anencephaly

Previous breech delivery

Uterine anomalies

Pelvic tumors


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The lowerextremities areflexed at the hips

and extended at theknees, and thus thefeet lie in closeproximity to the

head.


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One or both hips arenot flexed and one orboth feet or knees liebelow the breech, suchthat a foot or knee islowermost in the birthcanal.

Footling breech is an

incomplete breechwith one or both feetbelow the breech.


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The sacrum is the denominator of breech and thereare 6 positions:

a)Right sacro posterior

b)Left sacro posteriorc)Right sacro lateral

d)Left sacro lateral

e)Right sacro anterior

f)Left sacro anterior

The commonest position is assumed at left sacroanterior.


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Left sacrum anterior (LSA)the buttocks, as against theocciput of the vertex presentation, like close to the vagina

(hence known as breech presentation),which like anteriorlyand towards the left.

Right sacrum anterior (RSA)the buttocks face anteriorlyand towards the right.

Left sacrum posterior (LSP)the buttocks face posteriorlyand 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.


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Leopold maneuvers

First : the hard, round, readily ballotable fetal head is foundto 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 passedthrough the pelvic inletthe breech is movable above thepelvic inlet.

Fourth: shows the firm breech to be beneath the symphysis.

Fetal heart sounds usually are heard loudest slightly above the umbilicus,whereaswith engagement of the fetal head, the heart sounds are loudest below theumbilicus.


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Frank breech presentation:

both ischial tuberosities, the sacrum, and the anus usually arepalpable, and after further descent, the external genitalia may bedistinguished.

During prolonged labor, the buttocks may become markedly swollen,rendering differentiation of face and breech very difficultthe anusmay be mistaken for the mouth and the ischial tuberosities for themalar eminences.


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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 intothe pelvic cavity, the genitalia may be felt.


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VD

Frank positionGA>34w

FW=2000-3500grAdequate pelvisFlexed headNonviable fetusNo contraindication

Good progress labor

CS

FW> 3500grFootling

Small pelvisDeflexed headArrest of laborGA24-34wElderly PG

Inf or poor historyFetal distress


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Spontaneous breechdelivery.

The infant is expelled

entirely spontaneouslywithout any traction ormanipulation otherthan support of theinfant.


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Partial breech extraction.

The infant is deliveredspontaneously as far asthe umbilicus, but theremainder of the body isextracted or deliveredwith operator tractionand assisted maneuvers,with or withoutmaternal expulsiveefforts.


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Stage of Labor

Fetal Condition

Fetal Monitoring

Route of delivery

Timing of Delivery


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The fingers should reston the anterior superioriliac crests and thethumbs on the sacrum,minimizing the chanceof fetal abdominal softtissue injury


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Maternal expulsiveefforts are used inconjunction withcontinued gentledownward operatorrotational traction toeffect delivery of thefetus.


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Extraction of a frankbreech may be requiredand can be accomplishedby moderate tractionexerted by a finger ineach groin andfacilitated by a generousepisiotomy


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Two fingers are carried upalong one extremity to theknee to push it away fromthe midline.

Spontaneous flexionusually follows, and thefoot of the fetus is felt toimpinge on the back of thehand.

The fetal foot then may begrasped and broughtdown.


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During total extraction of acomplete or incompletebreech, the hand isintroduced through the

vagina and both feet of thefetus are grasped.

The ankles are held withthe second finger lying

between them and, withgentle traction, the feet arebrought through the vulva.


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As the legs begin toemerge through thevulva, downward gentletraction is thencontinued. As the legsemerge, successivelyhigher portions aregrasped, first the calves

and then the thighs


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A cardinal rule insuccessful breechextraction is to employsteady, gentle, downwardrotational traction until thelower halves of thescapulas are deliveredoutside the vulva, makingno attempt at delivery ofthe shoulders and armsuntil one axilla becomesvisible.


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Leverage is exerted on theposterior shoulder, whichslides out over the perinealmargin, usually followed

by the arm and hand.


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By depressing the body ofthe fetus, the anteriorshoulder emerges beneaththe pubic arch, and the

arm and hand usuallyfollow spontaneously.


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If the nuchal arm cannot befreed in the mannerdescribed, extraction maybe facilitated, especiallywith a single nuchal arm,by rotating the fetusthrough half a circle insuch a direction that thefriction exerted by thebirth canal will serve todraw the elbow toward theface.


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Mauriceau Maneuver The index and middle

finger of one hand areapplied over the maxilla,to flex the head, while thefetal body rests on thepalm of the hand andforearm

It is emphasized that

with this maneuver,the operator uses both hands

simultaneously and in tandem to exertcontinuous downward gentle tractionsimultaneously on the fetal neck and onthe maxilla.


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Prague Maneuver The back of the fetus fails

to rotate to the anterior.When this occurs, rotationof the back to the anterior

may be achieved by usingstronger traction on thefetal legs or bony pelvis.

If the back still remains orientedposteriorly, extraction may beaccomplished using the Mauriceau

maneuver and delivering the fetus backdown. If this is impossible, the fetus stillmay be delivered using the modifiedPrague maneuver, which, as practicedtoday, consists of two fingers of one handgrasping the shoulders of the back-downfetus from belowwhile the other handdraws the feet up over the maternal

abdomen


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Piper forceps

Laufe forceps Applied electively or when the Mauriceau

maneuver cannot be accomplished easily.

The blades of the forcepsshould not be applied tothe aftercoming head until

it has been brought intothe pelvis by gentletraction, combined withsuprapubic pressure, andis engaged.

Suspension of the body ofthe fetus in a toweleffectively holds the fetusand helps keep the armsout of the way.


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A procedure in which the fetal presentation isaltered by physical manipulation, eithersubstituting one pole of a longitudinal

presentation for the other or converting anoblique or transverse lie into a longitudinalpresentation.


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Recommendations:

External Cephalic version (ECV): uncomplicated breechpresentation in the 36th week age og gestation.

Cesarean section is recommended if ECV failed (term,singleton breech presentations)- it decreases perinatalmortality and neonatal morbidity.

CS is preferred mode of delivery because of diminishingexpertise in vaginal delivery


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At Tern, reduced the number of non vertex births.

Complications:

Fetal heart rate abnormalities- TRANSIENTBRADYCARDIA- most common

Abruptio placenta

Painless vaginal bleeding

Admission for induction of labor

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Breech Delivery Technique

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