Malposition - Breech Presentation.pptx

8/22/2019 Malposition - Breech Presentation.pptx

1/133

Breech Presentation


2/133

PRESENTED BY,

Dr. (Mrs). S. Anuchithra,

Vice Principal Cum HOD OBG Nursing,

P.D.Bharatesh College of Nursing,

Halaga, Belgaum.


3/133

Meaning

An unusual presentationNot to be considered abnormal - fetus lies

longitudinally with the buttocks in the lowerpole of the uterus.

Presenting diameter is the bitrochanteric

(10cm)

Denominator the sacrum.


4/133

Breech presentation


5/133

Breech presentation


6/133

Breech presentation


7/133

It is the commonest malpresentation

Reassure mother for normal labour and birth.

Ensuring informed consent - that not all

breech babies can or should be born vaginally.


8/133

IncidenceBreech Presentation

1 in 5 at 28th week

5% at 34th week - 3 out of 4, spontaneous

correction in to vertex

In mid-trimester frequency is much higher -

greater proportion of amniotic fluid facilitatesfree movement of the fetus.


9/133

The incidence in all pregnancies is about 3-4%.

Advancing gestational age - % of breech

deliveries decreases

25% of births prior to 28 weeks' gestation

7% of births at 32 weeks' gestation

1-3% of births at term.


10/133

Fetal abnormalities are observed in

17% of pre-term breech deliveries and

In 9% of term breech deliveries.

Cord prolapse occurs in 7.5% of all breeches.

This incidence varies with the type of breech:0-2% with frank breech,

5-10% with complete breech, and


11/133

10-25% with footling breech.

Cord prolapse occurs twice as often in women

who have had previous pregnancy (or

multiparas) (6%) than in the first time

pregnancy (or primigravidas) (3%).


12/133

Nuchal arms(one or both

arms are wrapped around

the back of the neck)

present in 0-5% of

vaginal breech deliveries

and in 9% of breech

extractions.


13/133

Fetal head entrapment - result from an

incompletely dilated cervix and head that lacks

time to mould to the maternal pelvis - occurs

in 0-8.5% of vaginal breech deliveries.


14/133

Types or VarietiesComplete

Incomplete


15/133

Complete Breech Normal attitude of full flexion

is maintained.

The thighs are flexed at the

hips and the legs at the knees.

The presenting part consists of

two buttocks, external

genitalia and two feet.

Commonly present in

multipara.


16/133

Incomplete Breech

Due to varying degrees of

extension of thighs or legs

at the podalic pole.

Three varieties are possible


17/133

Incomplete Breech

Breech withExtended Legs

Footling

Presentation

Knee

Presentation


18/133

Breech with Extended Legs

Thighs are flexed on the trunk and

the legs are extended at the knee

joints.

The presenting part - the two

buttocks and external genitalia only.

Common in primigravida 70% -

tight abdominal wall, good uterine

tone and early engagement of

breech.


19/133

Footling Breech

Both the thighs and the

legs are partially

extended bringing the

legs to present at the

brim.


20/133

Knee presentation

Thighs are extended but

the knees are flexed,

bringing the knees down

to present at the brim.


21/133

Clinical varieties

Uncomplicated Defined as one where

there is no other

associated obstetric

complications apart

from the breech,prematurity being

excluded.

ComplicatedWhen the presentation is

associated with

conditions which

adversely influence the

prognosis - prematurity,twins, contracted pelvis,

placenta praevia etc.


22/133

Six positions - Breech Presentation

RSP LSP RSL LSL

RSA LSA


23/133

EtiologyCause remains obscure.

Prematurity

Factors preventing spontaneous versionFavourable adaptation

Undue mobility of the fetusFetal abnormality

Recurrent or habitual breech


24/133

Diagnosis

I. Antenatal diagnosis

a.Abdominal examination,

b. Ultrasound examination,c. X-ray examination

II. Diagnosis during laboura. Abdominal examination,

b. Vaginal examination


25/133


a. Abdominal examination 1. Listen to the mother,

2. Palpation and

3. Auscultation


26/133


2. Palpation

Primigravida difficult to diagnose - firm

abdominal muscles.

Lie is longitudinal with a soft presentation-

easily felt using pawliks grip

Head felt in the fundus - round hard mass.


27/133

May be made to move independently - with one

or both hands.

Extended legs & feet prevents nodding.

When the breech is anterior and the fetus well

flexed - may be difficult to locate the head - but

use of the combined grip (upper and lower

poles) may aid diagnosis.


28/133


3. Auscultation

FHS clear above umbilicus - If breech has not

passed through the pelvic brim.

FHS heard at a lower level - when legs are

extended & breech descends into the pelvis.

I A t t l di i


29/133

I. Antenatal diagnosisb. Ultrasound examination

Used to demonstrate a breech presentation.

(1) Confirms the clinical diagnosis

(2) Can detect fetal congenital abnormality

(3)Measures biparietal diameter, GA and approximate

weight of the fetus.

(4) Locates the placenta.

(5) Assessment of liquor volume (important for ecv).

(6) attitude of the head

I A l di i


30/133


c. X-ray examinationAdded advantage - allowing pelvimetry to beperformed

A straight x-ray is rarely done:

(1) To confirm the clinical diagnosis.

(2)To exclude bony congenital malformation

(hydrocephalus).(3) To note the size of the baby.

(4) To note the position of the limbs and the head.

II Di i d i l b


31/133

II. Diagnosis during labour

a. Abdominal examinationExamination Complete breech Frank breech

Per

abdomen

Fundal grip

Head suggested

by hard and

globular mass.

Head is ballotable.

Head irregular small parts

of the feet may be felt by the

side of the head.

Head is non-ballotable due

to splinting action of the legs

on the trunk

Examination Complete breech Frank breech


32/133


Lateral grip Fetal back is to one side

and the irregular limbs to

the other.

Irregular parts are less

felt on the side

Pelvic grip Breech suggested by

soft, broad and irregular

mass.Breech usually not

engaged during

re nanc .

Small hard and conical

mass is felt

The breech is usuallyengaged



33/133


FHS Usually above

the umbilicus

Located in lower level in the

midline due to early

engagement of the breech

Per vaginal

During

pregnancy

Soft, irregular

parts are felt

through the

fornix

Hard feel of sacrum is felt,

often mistaken for the head.

Palpation of ischial

tuberosities, anal opening and

sacrum only.


34/133

II. Diagnosis during labour

b. Vaginal ExaminationThe breech feels soft and irregular with no

sutures palpable,

Occasionally the sacrum may be mistaken for a

hard head and the buttocks mistaken for caputsuccedaneum.


35/133

The anus may be felt and fresh meconium on

the examining finger is usually diagnostic.

If the legs are extended - external genitalia are

very evident (become edematous).

An edematous vulva may be mistaken for a

scrotum.


36/133

If a foot is felt - differentiate it from the hand.

Toes are all the same length,

shorter than fingers and the big toe cannot be

opposed to other toes.

The foot is at right angles to the leg, and

the heel has no equivalent in the hand.


37/133

No feet felt; the legs are extended.Feet felt; complete breech presentation


38/133

Antenatal Management

Identification of the complicating factors

External cephalic version

Formulation of the line of management


39/133

Identification of the

complicating factorsClinical examination,

Sonography- useful to detect

Congenital malformations of the fetus,

The precise location of the placental site and

Congenital anomalies of the uterus.


40/133

External cephalic version

Definition: External cephalic version (ECV) is

the use of external manipulation on themothers abdomen to convert a breech to a

cephalic presentation.


41/133

The success rate of version is about 60%

Successful version reduces the risk of

caesarean section significantly.

Prior Sonography should be a routine.

Cardiotocography should ideally be done

before and after the procedure.


42/133

Time of version:

At 35-37 weeks but can be attempted at any

time thereafter up to early labour.

Version in the early weeks is easy but chance of

reversion is more.

Late version may be difficult - increasing size ofthe fetus and diminishing volume of liquor

amnii tocolysis makes less difficult.


43/133

Time of version:

Routine version at 35 to 37 weeks may have

advantages.

It minimises chance of reversion and

Developed fetal complications can be

effectively tackled by caesarean section.Hypertonus or irritable uterus can be

overcome with the use of tocolytic drugs.


44/133

Benefits of ECV are

Reduction in the incidence of breech

presentation at term,

Reduction in the incidence of breech delivery

and the associated complications,

Reduction in the incidence of caesarean

delivery by 5%.


45/133

Successful version is likely in cases of:

Complete breech,

Non-engaged breech sacroanterior position,

Adequate liquor

Non obese patient.


46/133

Causes of failure of version:

Breech with extended legs- difficult to

disimpact because of early engagement and

difficult to flex the trunk because of splinting

action of the limbs,

Scanty liquor

Big size baby.


47/133

Causes of failure of version:

Mechanical

Obesity,

Increased tone of the abdominal muscles and

Irritable uterus.

Short cord - either relative or absolute,

Uterine malformations- septate or bicornuate.


48/133

Method

An ultrasound scan

To localize the placenta

To confirm the position and

Presentation of the fetus.

If tocolysis site a cannula to allow venous

access.


49/133

Method

A 30min CTG

To confirm no fetal compromise

Maternal blood pressure and

Pulse.

Ask woman to empty her bladder.

Provide a comfortable supine position.


50/133

Method

Elevate the foot of the bed - help free the

breech from the pelvic brim.

Dust the abdomen with talcum powder - to

prevent pinching of the mothers skin during

the procedure.


51/133

Method

ECV - uncomfortable but it should not bepainful.

The breech is displaced from the pelvic brimtowards an iliac fossa.

Simultaneous force is then used as with one

hand on each pole the operator makes the fetus

perform a forward somersault (Fig).


52/133

Pressure is exerted on head and breech

simultaneously until the head is lying at the pelvic

brim.

Flexion is continued. The left hand brings thehead downwards. The right hand pushes the

breech upwards.

The right hand lifts the breech out of thepelvis. The left hand makes the head follow

the nose. Flexion of head and back is

maintained throughout.


53/133


54/133


55/133


56/133


57/133

Method

If this is not successful then a backward

somersault can be attempted.

If fetus does not turn easily, then the procedure

is abandoned but may be tried again a few days

later.


58/133

Repeat CTG following the procedure.

Rhesus negative woman an injection of anti-D

immunoglobulin - prophylaxis against

isoimmunization caused by any placental

separation.


59/133

If the version is performed immediately

prior to the onset of labour, this can be

delay Injection - until after birth when the

blood group of the baby is known.

In this case if anti-D is needed, it must be

given within 72hrs of the version.


60/133

Dangers of version

Premature onset of labour,

Premature rupture of the membranes,

Placental separation and bleeding,

Entanglement of the cord - round the fetal part

or formation of a true knot - impairment of

fetal circulation and fetal death and,


61/133

Dangers of version

Increased chance of feto-maternal bleed and

Amniotic fluid embolism.

Immunoprophylaxis with anti-D gamma

globulin for non-immunized Rh- negative

mother.

Management if version fails or is


62/133

Management-if version fails or is

contraindicated

Continue pregnancy - usual check up and possible

unexpected spontaneous version

But if the breech persists case assessment to bedone

Age of the mother especially in primigravida

Size of the baby and,

Pelvic capacity.


63/133

Clinical assessment of the pelvis - all

primigravida

CT or MRI is a better alternative.

Ultrasonographic examination - gold standard for

decision making.

Two methods of delivery can be planned.

Elective caesarean section.

To allow spontaneous labour to start and vaginal

breech delivery to occur.


64/133

Elective Caesarean section

Tendency to liberalize the caesarean section -risk involved in vaginal breech delivery

The indications of C.S. In breech areBig baby fetal weight >3.5kg

Hyperextension of the head

Footling presentation.

Any associated complication


65/133

The overall incidence of CS in breech range

from 15-50%, out of which about 80% is

elective.

Delivery of preterm breech by caesarean

section is commonly done but in selected

centers, equipped with intensive neonatal

care unit.


66/133

Vaginal breech delivery

Considered in cases with

Adequate pelvis,

Average fetal weight flexed head and

Without any other complications.

Frank breech is preferred - ensure closemonitoring of labour and facilities for

immediate caesarean delivery.


67/133

Complications

Knotting of the umbilical cord

Separation of the placenta

Rupture of the membranes


68/133

Relative contraindications

The presence of a uterine scar


69/133

Contraindications

Pre-eclampsia or hypertension

Multiple pregnancy

Oligohydramnios

Ruptured membranes

Any condition that would require delivery by

caesarean section.


70/133

Persistent breech presentation

Mechanism of left sacroanterior


71/133

Mechanism of left sacroanterior

position

Description of fetus The lie is longitudinal

The attitude is one of complete flexion

The presentation is breech

The position is left sacroanterior

The denominator is the sacrum

The presenting part is the anterior (left) buttock

The bitrochanteric diameter, 10cm, enters the pelvis in the left oblique

diameter of the brim

The sacrum points to the left iliopectineal eminence.


72/133

Main Movements of LSA

Compaction

Internal rotation of the buttocks

Lateral flexion of the body Restitution of the buttocks

Internal rotation of the shoulders

Internal rotation of the head

External rotation of the body

Birth of the head


73/133

Management of vaginal breech

deliveryFirst stage

The management protocol is similar in normallabour.

Spontaneous onset labour increases thechance of successful vaginal delivery.

First stage


74/133

First stageVaginal examination is indicated

Onset of labour - pelvic assessment.

Soon after ROM to exclude cord prolapse.

An intravenous line is sited

Ringers solution,

NPO

Blood is sent for group and cross matching


75/133

First stage

Adequate analgesia - preferred epidural.

Monitor Fetal status and progress of labour

Oxytocin infusion - augmentation of labour.

di i f i


76/133

Indication of Caesarean Section

(C.S.)Cases seen for the first time in labour with

presence of complications.

Arrest in the progress of labour.

Non-reassuring fhr pattern (fetal distress).

Cord presentation or prolapse.

I l b


77/133

IV fluidsKeep fastingGive anti acidPartogramContinuous fetal monitoring

AnalgesiaInform neonatologistKeep theater staff and the anesthetistInformed

In labor

1st stage of labor :

Proper historyReview of the A.N c. RecordsInvestigation


78/133

Early Care In First Stage of Labour

Cleanliness and Comfort

i) Bowel Preparation

ii) Perineal Shaveiii) Bath or Shower

iv) Clothing


79/133

Early Care In First Stage of Labour

Analgesia

Records

Drug Records


80/133

SECOND STAGE

There are three methods of vaginal breechdelivery

Spontaneous (10%) very little assistanceAssisted breech Assistance from beginning to

end

Breech extraction - entire body of the fetus is

extracted by the obstetrician


81/133

SECOND STAGE

Breech extraction

Indications are:

Delivery of the second twin

Cord prolapsed

Extended legs arrested at the cavity or at

the outlet.

ASSISTED BREECH DELIVERY


82/133


Conducted by a skilled obstetrician.

The following are to be kept ready

beforehand in addition

Anaesthetist

An assistant



83/133


Instrument and suture materials forepisiotomy

A pair of obstetric forceps - after cominghead

Appliances for revival of the Baby-Asphyxiated


84/133

Principles in conduction

Never to rush,

Never to pull from below but push from

above,

Always keep the fetus with the back

anteriorly.

Steps


85/133

Steps

Woman brought to the table - anterior buttock

and fetal anus are visible - place in lithotomy

position when the posterior buttock distends

the perineum.

Woman is tilted laterally using wedge under

the back - to avoid aortocaval compression.

Steps


86/133

Steps

Antiseptic cleaning,

Bladder is emptied with catheterization.

Pudendal block with perineal infiltration orepidural

Episiotomy - best time - the perineum is

distended and thinned by the breech.


87/133

The patient is encouraged to bear - ensure

flexion of the fetal head and safe descent.

Policy adopted - no touch - until the buttocks

are delivered along with the legs in flexed

breech and the trunk slips up to the umbilicus.


88/133

Soon after the trunk up to the umbilicus is

born. The Following are to be done:

The extended legs

The umbilical cord

If the back remains posteriorly

The baby is wrapped


89/133

Delivery of the arms

Assistants gives steady fundal pressure during

uterine contractions to prevent Extension of the

arms.

Soon, the anterior scapula is visible - position of

the arm should be noted.


90/133

When the arms are flexed-vertebral border of

the scapula - parallel to the vertebral column

and when extended - winging of the scapula.

The arms are delivered one after the other only

when one axilla is visible-hooking down each

elbow with a finger.


91/133

Breech delivery. Delivering the buttocks (A); feeling for the arms for deliveryone at a time (B); the hairline over the nape of the neck is visible (C); lifting

the legs slowly over the mothers abdomen (D).

Delivery of the after coming head


92/133

Delivery of the after-coming head

Most crucial stage of the delivery.The time between the delivery of umbilicus to

delivery of mouth should preferably be 5 to 10minutes.

There are various methods of delivery for the

aftercoming head.

Delivery of the after coming head


93/133

Delivery of the after-coming head

Each one is quite safeEffective in the hands of an expert,

conversant with that particular technique.

Employed common methods are:

Burns Marshall Method

Forceps delivery

Malar flexion and shoulder traction



94/133

Burns Marshall MethodThe baby is allowed to hang by its own weight.

Assistant - gives suprapubic pressure with the

flat of hand in a downward and backward

direction-more towards the sinciput - aim is

to promote flexion of the head so favourable

diameter is presented to the pelvic cavity. Not

> 1-2 minutes are required to achieve the

objective


95/133

When the nape of the neck is visible under

the pubic arch, the baby is grasped by the

ankles with a finger in between the two.

Maintaining a steady traction and forming a

wide arc of a circle, the trunk is swung in

upward and forward direction.


96/133

Meanwhile, with the left hand to guard the

perineum, slipping the perineum off

successively the face and brow. When the

mouth is cleared off the vulva, there should

be no hurry. Mucus of the mouth and

pharynx is cleared by mucus sucker.

The trunk is depressed to deliver rest of the

head


97/133



98/133


(A)The baby is grasped by the feet and held on the stretch.(B) The

mouth and nose are free. The vault of the head is

delivered slowly.


99/133

Forceps delivery

Malar flexion and shoulder


100/133

Malar flexion and shoulder

traction

MauriceauSmellieVeit


101/133

manoeuvre (jaw flexion and

shoulder traction)

MauriceauSmellieVeit manoeuvre for delivering the aftercoming head of breech presentation

(A) The hands are in position before the body is lifted. (B) Extraction of the head.


102/133

Resuscitation of the baby: The baby may be

asphyxiated and need to be resuscitated.


103/133

THIRD STAGE

Usually uneventful.

The placenta is usually expelled out soon afterdelivery of the head.

Prophylactic ergometrine- administered

intravenously with the crowing of the head.


104/133

Preterm breech

ECV with preterm breech presentation is

not recommended.

Cs - fetal weight is


105/133

BREECH DELIVERY

Delay in Descent of the breech

Frank Breech Extraction

Extended Arms - Lovsets ManeuverNuchal displacement of arm

Arrest of the After coming head

Delivery of the head through an incompletely

dilated cervix


106/133

Delay in Descent of the breech

The breech may be arrested:

At the outlet

In the cavity

At the brim

Arrest At the outlet


107/133

Arrest At the outlet

Causes areBig size baby with extended legs

(commonest)Weak uterine contractions

Rigid perineum and

Outlet contraction.

Management


108/133

g

Caesarean section: outlet is contracted, baby

is big.

In the absence of outlet contraction and

fetopelvic disproportion

Liberal episiotomy and fundal pressure

Arrest of the breech at or above


109/133

Arrest of the breech at or above

the level of ischial spines

The causes of arrest are-contracted pelvis,

weak uterine contractions, big baby.

Management:

Best treatment - delivery by ceasarean

section.



110/133


Intrauterine manipulation to convert a frankbreech to a footling breech.

Possible - membranes have ruptured recently.



111/133


In pinards maneuver - the middle and theindex fingers are carried up to the popliteal

fossa. It is then presses and abducted so that thefetal leg is flexed. The fetal foot is then grasped

at the ankle and breech extraction is

accomplished.


112/133

Pinards maneuver

Extended Arms


113/133

Extended Arms

One or both the arms are fully stretched along

the side of the head or lie behind the neck.

The cause - faulty technique in delivery- usingunnecessary traction, forgetting the principle

of never pull but push from above.

Extended Arms


114/133

Arrest - delivery of the trunk up to the costal

margins.

Diagnosis - by noting the winging of the

scapula and absence of the flexed limbs in front

of the chest.

M t


115/133

Management

Urgent delivery of the arms - first the

posterior and then the anterior one.

Any one of the following methods: classical,

lovset.

Management - Classical


116/133

Same principle - lovsets maneuver.

Addition - intra uterine manipulation with

patient is in GA.

First - posterior arm is delivered followed by

the anterior arm.

L f h d i i d d l h f h


117/133

Left hand is introduced along the curve of the

sacrum while the baby is pulled slightlyupwards.

With firm pressure over the humerus, theposterior arm is pushed over the babys face.

The extended anterior arm is in the same

manner, while the babys trunk is depressed

towards the perineum.

Management - Lovsets Maneuver


118/133

Widely practiced

Advantages

Wider applicability

Intrauterine manipulation is nil,

A single manipulation is effective

General anesthesia is usually not needed.

Management - Lovsets Maneuver


119/133

Principles:

Because of curved birth canal, when the anterior

shoulder remains above the symphysis pubis, the

posterior shoulder will be below the sacralpromontory.

If the fetal trunk is rotated keeping the back

anterior and maintaining a downward traction,

the posterior shoulder will appear below the

symphysis pubis.

Procedure


120/133

The baby is grasped, using both hands by

femoropelvis grip keeping the thumbs parallel

to the vertebral column.

Start only when the inferior angle of the

anterior scapula is visible underneath the

pubic arch.

Procedure


121/133

Step-1:

Lift baby slightly to cause lateral flexion.

The trunk is rotated through 180 keeping the

back anterior and maintaining a downward

traction.

Posterior arm to emerge under the pubic arch -

hooked out.


122/133


123/133

Procedure


124/133

Step-2:

Rotate the trunk in the reverse direction

keeping the back anterior to deliver the

erstwhile anterior shoulder under the

symphysis pubis.

Nuchal Displacement of Arm


125/133

p

Arm is flexed at the elbow and extracted at theelbow and extended at the shoulder and lies

behind the fetal head.

Lovsetts maneuver.

If this fails, the arm is forcibly extracted by

hooking - fracture almost always follows


126/133

Arrest of the Aftercoming head

At

Brim

Cavity

Outlet



127/133

g

at Brim

The causesdeflexed head, contracted pelvis

and, hydrocephalus.

Management:

If the arrest by a deflexed head - completed by

malar flexion and shoulder tractionalong with

suprapubic pressure by the assistant.



128/133

g

at Brim

The head is to be negotiated though the brim in

the transverse diameter and rotated in the cavity.

Forceps should not be applied in high head.

If the arrest of the head - contracted pelvis or

hydrocephalus, perforation of head is to be done.

Arrest of the Aftercoming head In


129/133

g

the cavity

Causes - deflexed head and, contracted pelvis.

The best management is delivery of the

head by forceps which is effective in both the

circumstances.

Malar flexion and shoulder traction - only in

deflexed head.



130/133

g

At the outlet

The causes - rigid perineum and, deflexed

head.

Episiotomy followed by forceps application or

Malar flexion and shoulder traction is quite

effective.

Delivery of the head through an


131/133

incompletely dilated cervix

Causes premature baby, macerated baby, and

footling presentation and, hasty delivery of

breech before the cervix is fully dilated.

Delivery of the head through anincompletely dilated cervix


132/133

incompletely dilated cervix

Management:

If the baby is living- push up the cervix, malar

flexion and shoulder traction (Shoe- HornMethod).

If necessary, Duhrssens incision can be madeat 2 and 10 Oclockposition on the cervix.

Occipito- posterior position of thehead


133/133

headUsually occurs in spontaneous breech delivery.

The fetal trunk and the head are rotated to

bring them anteriorly.

For rotation, the fetal trunk and the head are

to be grasped; the hand and the fingers are

poisoned like that in malar flexion and

Date post:	08-Aug-2018
Category:	Documents
Upload:	radhakrishnan-govindan
View:	227 times
Download:	0 times

Malposition - Breech Presentation.pptx

Documents