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Vaginal Breech Delivery
Prof. dr. Mgs. H. Usman Said, SpOG (K)
Subbagian Fertilitas Endokrinologi & ReproduksiDepartemen Obstetri & GinekologiFK. Unsri / RSUP Dr. Muhammad Hoesin Palembang2010
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• Objectives– Incidence and Significance– Selection– Management
– Intrapartum– Delivery
• Definition– longitudinal lie– breech or lower extremity presenting– cephalic pole in the uterine fundus
• Types– frank - flexed hips, extended knees– complete - flexed hips, flexed knees– footling - extended hip(s)
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• Types of Breech
Complete Footling Frank
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• Incidence– 3 to 4% of all pregnancies– increases with decreasing gestational age
– 7 to 10% at 32 weeks– 25 to 35% at < 28 weeks
Etiology of Breech Presentation
idiopathic prematurity (head to trunk size) uterine or pelvic structural abnormality uterine fibroid fetal anomaly or abnormality polyhydramnios multiple gestation
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• Diagnosis – maternal perception of movement– Leopold’s maneuvers– FH auscultated above umbilicus– vaginal exam– ultrasound– X-ray
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• Recommendations for Breech Delivery– recommend trial of labour at 36 weeks or
when estimated weight is 2500 to 4000 grams– offer trial of labour at 31 to 35 weeks gestation or
when estimated weight is 1500 to 2500 grams– offer caesasean section at 30 weeks gestation
or when estimated weight is < 1500 grams*– no recommendation for when estimated weight
is > 4000 grams*
* acknowledged lack of evidence for recommendation
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• Selection Criteria for Trial of Labour– frank or complete breech– fetal head not hyperextended–estimated fetal weight 2500 to 4000g
• Ultrasound Assessment
– confirm lie and type of breech– assess head position– obtain estimate of fetal weight– assess for IUGR and congenital anomalies– assess amniotic fluid volume– confirm placental localization
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• Contraindications to Trial of Labour– fetal or maternal contraindication to labour– footling breech– hyperextension of the fetal head– absence of informed consent– absence of experienced maternity health care
giver
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• Management at Delivery– experienced newborn resuscitator present– empty maternal bladder– maternity attendant with experience in breech delivery – forceps if available, may be helpful
• Management in Labour– planned delivery in hospital– admission in early labour or with ROM– appropriate fetal surveillance– epidural and ARM for usual indications– immediate vaginal exam at ROM to rule out cord prolapse– good progress in labour ( 0.5 cm/h after 3 cm)– induction and augmentation permissible
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• Entering the Pelvis
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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• Descent of the Breech
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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Spontaneous Expulsion
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
• spontaneous expulsion to the umbilicus
• the sacrum should be gently guided anteriorly
• singleton breech extraction is contraindicated
• C/S is indicated for failure of descent or expulsion
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• Hurry up & Wait! –DON’T PULL!–traction deflexes the
fetal head–may cause nuchal
arm
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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Deliver Legs by lateral rotation of thighs and flexion of knees - keep sacrum anterior
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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• Delivery of Arms– good maternal pushing– deliver when winging of
scapulae seen– rotate arm to anterior– sweep humerus across
the chest and deliver– rotate other arm
anterior and repeat to deliver
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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• Avoid Over-extension
Obstetrics - Normal and Problem Pregnancies,2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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Delivery of the head
• Mauriceau - Smellie - Veit manoeuvre to deliver the head in flexion
• The body should be supported in a horizontal position
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• Delivery of the head
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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• Delivery of the head– Forceps– assistant elevating
babe– direct application
Obstetrics - Normal and Problem Pregnancies, 2nd EditionEdited by SG Gabbe, JR Niebyl, JL Simpson. (1991)
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• Prevention of Breech– consider external cephalic version at 36
weeks gestation for eligible candidates– success rate 30 - 70% depending on experience
– results in lower cesarean section rate
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• Conclusions– proper selection of patients– thorough explanation and informed consent– good progress in labour ( 0.5 cm/h after 3 cm)– induction and augmentation permissible– experienced attendants– standard fetal monitoring– assisted delivery - DON’T PULL - stay cool!
