OPERATIVE OBSTETRICS

BREECH : Definition,Incidence & Significance

• fetal buttocks or feet enter maternal pelvis before the baby’s head

• Breech presentation affects 3 – 4 % of all pregnant women reaching term

• associated with increased perinatal morbidity, due to PREMATURITY, CONG. ANOMALIES, BIRTH TRAUMA, ASPHYXIA

Varieties of breech presentation

(relationship bet.lower extremities & buttocks/hips determines the variety)

1) FRANK BREECHlower extremities flexed at the hips & extended at the knees extended legs are against the trunk, baby’s feet lie close to its head & against its face

most common breech pres. at term

2) COMPLETE BREECH

- Lower extremities flexed at the hips;

both knees are also flexed. Buttocks & knees are then at same level; feet also alongside buttocks in front of abdomen

3)INCOMPLETE BREECH

- One or both hips are extended so that one or both feet &/or knees lie are below the breech/buttocks, and may be prolapsed into the mother’s vagina

Diagnosis of Non-Vertex Pres.

• Fundal grip• Umbilical grip• Pawlick’s grip• Pelvic grip• Auscultation of FHT with Pinard fetoscope• Digital vaginal exam / IE• Sonology (other info. here are AFI,

placental localization, cord posn. , pres. of fetal abnies)

hyperextended head, mother’s abd. x-ray

Etiologic & Predisposing Factors

• In majority of breeches, no etiology is identifiable

• Predisposing to & associated w/ breech: - prematurity - uterine abnormalities & pelvic tumors - abnormal AFV - multiple gestations - placenta previa - fetal anomalies

It is very important to rule out seriousfetal congenital anomalies prior to Cesarean Section delivery for breech.

Management remains controversial

• Planned CS for term breech delivery, based on Term Breech Trial (Hannah et.al., 2000). This multicentric RCT & a meta-analysis of all breech trials have shown that one neonatal death is prevented for every 112 planned CS ; maternal long-term risks not yet addressed

• Planned vaginal term breech delivery

RECOMMENDATIONS FOR DELIVERY

CAESAREAN DELIVERY: a large fetus more than 3.6kg. any degree of contraction or unfavorable

shape of the pelvis (may do x-ray, CT or MRI) a hyper-extended head, or BPD above 10cm no labor, & with additive maternal/fetal indication

for delivery (e.g. HPn, ruptured membranes for

12 hrs. or more)

Uterine dysfunction Footling presentation or incomplete breech Apparently healthy yet preterm fetus of 26

wks AOG or more, or w/ 1-2kg wt . & mother in active labor or in imminent delivery

Severe IUGR or chronic fetal distress Previous hx of perinatal death, or children

suffering from birth trauma;hx of difficult del. Request for sterilization

VAGINAL DELIVERY- for a frank or complete breech presentation 36 weeks or more and with:

Adequate maternal pelvis EFW < 3600 gms. or between 2.5-3.6kg. Normal labor course w/ good cervical dilatation

and effacement Competent and available OB, Anes, Pedia

Planned vaginal birth for breech

• Can also be offered for either frank or complete breech at 31-35 wks. gestation, and/or when estimated BW is 1.5-2.5 kg.

• The woman’s wishes, in collaboration with the attending healthcare providers’ judgment, should determine which delivery method (abd. or vag.) is most appropriate.

MANAGEMENT OF LABOR & DELIVERY

• Admission to del.facility in early labor, or after sROM• Appropriate fetal monitoring• Epidural anesthesia for usual indications• Amniotomy for same indications• Immediate IE at membrane rupture TO RULE OUT CORD

PROLAPSE! • Assess labor progress & expect same progress as in vertex

presentation • Mother’s bladder should be emptied prior to delivery• Selective episiotomy preferable to routine episiotomy• Experienced healthcare team Ö

Types of VAGINAL BREECH DELIVERY

a. Spontaneous breech delivery - infant is entirely expelled by natural

forces of the mother, unassisted except for support of the baby as it is born

- infrequent; usually in multiparas, with

rapid expulsion of fetus

b. Assisted Breech Delivery

1) Partial breech extraction - infant is delivered by natural forces up to navel/umbilicus; then the rest

of the body & after-coming head are

extracted

- the best method of vaginal breech delivery

2) Total or complete breech delivery

- fetus is delivered entirely by extraction

- in second of twins (second twin must not be much bigger than first); done by experienced OB, under

anesthesia

Delivery of aftercoming

head

a. Mauriceau -Smellie-Veit Maneuver: index &

middle fingers of one hand over maxilla to

flex head, while fetal body rests upon palm

and forearm of obstetrician

b. Prague maneuver – Kiwisch of Prague (1846) ; two fingers grasp shoulders of back-down fetus while other hand draws feet up over abdomen of mother

c. Bracht Maneuver

- breech delivers up to umbilicus; fetal body held but not pressed against maternal symphysis, only allow gravity to work ;

uterine contractions + supra-pubic pressure spontaneous delivery

d. Forceps (Piper’s)

- should be applied only when the head is

well within pelvic cavity

- assistant may wrap baby’s body in towel to

keep the arms out of the way (Savaj maneuver)

e. Entrapped head (rare; greater frequency w/

preterm breech)

- Duhrssen incisions at 2, 6, 10 o’clock of cx;

cervix should be fully effaced and at

least 7 cms dilated ;

- Symphysiotomy

f. Abdominal Rescue

- for entrapped head stat CS

- DON’T PANIC!

Some Variations in Partial Breech Delivery:

• If the fetal sacrum rotates backwards after delivery of the breech, this must be manually corrected so that head does not enter pelvis in posterior position.

Extraction of Frank Breech

- delivered by moderate traction exerted

by a finger in each groin

- breech decomposition (to convert frank

to footling breech); Pinard maneuver

pushes fetal knee from midline (abduct)

in backward outward direction flexion

For extended arm/nuchal arm:

Arms are normally folded across chest and freed after shoulder delivery. Especially in preterm infants the arm may be pulled and may become extended over the head. OB manipulates this by rotating the baby’s

body in order to induce flexion of arms. For nuchal arm, rotate fetus to release arm.

Or, do LOVESET maneuver.

Partial Breech Extraction:

No intervention is done until after body is born up to umbilicus of the baby.

Bearing down by mother is encouraged & may be aided by an assistant who exerts supra-pubic pressure.

• Premature traction/pulling can cause de-flection

of head and extension of arms above or behind the neck.

The moment the umbilicus comes out, the

rest of the delivery should be accomplished

within 3-5 minutes.

*Time becomes an important factor!

Cardinal rule in delivery of shoulders:Do not attempt delivery of shoulders

and arms until downward traction makes

oneaxilla visible.

Do not panic! AVOID PULLING ON THE BREECH !!!

- A Competent Team:skillful obstetrician

assistants, medical & nursing

anesthesiologist

pediatrician

COMPLICATIONS OF BREECH DELIVERY

MATERNAL

1. Infection

2. Uterine rupture

3. Cervical lacerations

4. Uterine atony

However, prognosis for mother is better in vaginal breech delivery than in C.Section.

FETAL Complications – poorer fetal/neonatal prognosis in vaginal delivery

1. Tentorial tears, intra-cerebral bleed

2. Cord prolapse

3. Fracture of clavicle, humerus

4. Paralysis of arm

5. Broken neck

6. Testicular injury

VERSION

- An operation in which the presentation of the fetus is altered artificially

a. Substitute one pole of a longitudinal

presentation for the other

b. Converting an oblique or transverse

lie into a longitudinal lie (cephalic or

podalic)

External version – manipulations done through abdominal wall (ECV)

Internal version– hand introduced into uterine cavity (internal podalic version)

External Cephalic Version

Usually with tocolysis Hook to fetal monitor Each hand grasps a fetal pole the

preferred presenting part is gently stroked to the pelvic inlet

Have OR ready

Internal Podalic Version

Feet grasped and drawn through cervix while body is pushed abdominally in opposite direction

For delivery of second of twin

Cesarean Section (CS) defined:

Delivery of a fetus through an abdominal incision

(laparotomy), followed by incision of the uterus(hysterotomy). Definition does not include removalof the fetus from the abdominal cavity after

uterinerupture or in an abdominal pregnancy.

CS Hysterectomy is removal of uterus in conjunction w/ a CS or abdominal delivery.

Reasons for increasing CS rates:

1. Safety of the operation2. Delivery of breech by CS3. Fear of uterine rupture after previous CS4. Fetal distress/nonreassuring FHR pattern as

indic.+ increased use of electronic fetal monitor

5. More preference to CS than operative vaginal deliveries, particularly mid-forceps

or difficult vaginal operative deliveries

Reasons for increasing CS rates:

6. Increasing age of marriage and childbearing;

hence, more elderly primis today ?7. Use of technology like USG & E.F.

monitoring8. Emphasis on patient’s rights and

autonomy (CDMR)

CS Indications

• Medical: maternal cardiac dse (unstable coronary artery disease), pulmo/resp. dse (Guillain-Barre syndrome), conditions associated w/ ICP

• Mechanical: tumor previa; obstruction of the vulva (massive condylomata)

• Fetal : FHR, malpresentation/malposition• Maternal-Fetal: dystocia due to CPD,

placenta abruptio or previa

Phil./ Local Indications for CS:

1. Obstructed labor2. Hemorrhagic complications3. Abnormal patterns of labor4. Fetal distress5. Previous CS (more than 30%)6. Cord complications7. Obstetric problems

Maternal mortality from CS is due tounderlying diseases rather than

surgery itself, except those cases

complicated by infection.Perinatal fetal morbidity is related to

age of gestation and prior status of baby .

Some Maternal Complications of CS

1. Injury to neighboring organs: urinary bladder, ureters, bowels, blood vessels in broad ligaments and uterine blood vessels;2. More risk of postpartum hemorrhage3. More risk of pulmonary embolism,4. Paralytic ileus5. Infection – wound infection, UTI6. Placenta previa accreta

• PLACENTA ACCRETA is reported to be the most frequent indication for postcesarean hysterectomy, while uterine ATONY is the most common reason for hysterectomy after a vaginal delivery.

• A sub-total hysterectomy is preferred when faster surgery is required, or dissection of cervix is difficult.

Vaginal Birth After Cesarean (VBAC)

one way to lower CS rates

Limited to cases where uterine incision is low transverse and no extension of the wound (previous CS of one low-segment incision), after excluding inadequate pelvis.

Advantages of VBAC

1. Vaginal births are associated with lower rate of infection and blood loss compared to CS.2. Babies born vaginally undergo a natural squeeze to expel fluid from esophagus, nose and lungs.3. Recovery time is faster after vaginal birth.4. Hospital stay is shorter.