dr. Udin Sabarudin Department of Obstetrics & Gynecology Medicine School of Padjadjaran University Bandung MECHANISM OF LABOR IN BREECH PRESENTATION
Frank (65%) : Hips are flexed, knees are extended. Complete (10%) : The hips and knees are flexed Incomplete (25%): The feet or knees are the lowermost presenting part. o Single footling : one of the lower extremities is lowermost. o Double footling : Both of the lower extremities are lowermost THE 3 TYPES OF BREECH PRESENTATION
Figure Breech presentations. A: Right sacrum posterior (RSP) position. B: Left sacrum anterior (LSA) position. (Redrawn and reproduced, with permission, from Bumm E: Grundiss zum Studium der Geburtshilfe. Bergmann, 1922)
PREDISPOSING FACTORS : Prematurity Uterine abnormalities :-Malformation; -Fibroids Fetal abnormalities :-CNS Malformations; -Neck Masses Multiple gestations Previous breech delivery
Gestational age and frequency of breech birth Gestational age in weeks% Breech
DIAGNOSIS : Palpation and ballottement Ultrasound Pelvic examination X-Ray studies
Leopold Maneuver
External Cephalic Version TTTT
MANAGEMENT DURING LABOR Type of Delivery Vaginal delivery: Spontaneous Partial breech extraction Total breech extraction Cesarean of delivery
Management
Three types of vaginal breech delivery exist Spontaneous breech (rare) : No manipulation of the infant is necessary, other than supporting the infant. Partial breech extraction : Fetus descend spontaneously to where umbilicus is at the vaginal introitus; then, the fetus is extracted completely. Total breech extraction : The entire body is extracted. This is indicated only if there is evidence of fetal distress unresponsive to routine maneuvers and a cesarean delivery is not possible.
Conditions are unfavorable for breech delivery Fetus weight more than 3500 g Unfavorable pelvis – Breech delivery does not allow sufficient time for molding of the fetal head; thus, a platypelloid or android pelvis decreases ability fetal head to navigate maternal pelvis Hyperextension of the head – increases risk of cervical spine injury Footlings- incidence of umbilical cord prolapse increases with coiling of the umbilical cord around the legs of the fetus
MORTALITY/MORBIDITY Increased birth trauma: As duration of umbilical cord compression increases → deliver the infant more rapidly → increasing birth trauma Decreased birth weight may result from preterm delivery/growth restriction Incidence of prolapsed umbilical cord depends on type of breech presentation : Footling 17%, Complete 5%, Frank 0,5%
Mechanism of Labor in Breech Delivery
Assisted Delivery of Frank Breech
Mechanism of Labor in Breech Delivery Figure Maneuver for delivery of the head. The fingers of the left hand are inserted into the infant’s mouth of over mandible; the right hand exerts pressure on the head from above. (Modified and reproduced, with permission, from Benson RC: Handbook of Obstetrics & Gynecology, 8 th ed. Lange, 1983)
Mauriceau Maneuver
Delivery of the Aftercoming Head Piper forceps Modified prague maneuver
Mechanism of Labor in Breech Delivery Figure Application of Piper forceps, employing towel sling support. The forceps are introduced from below, left blade first. Aiming directly and intended positions on sides of the head. (Reproduced, with permission, from Benson RC: Handbook of Obstetrics & Gynecology, 8 th ed. Lange, 1983)
Forceps to Aftercoming Head
Modified Prague Maneuver
Complete or Incomplete Breech Extraction
Breech Extraction
C-Section Indication o A large fetus ( > gr ) o A Hyperextended fetus o Uterine dysfunction o Footling presentation o Any degree of contraction or unfavorable shape restriction o Previous perinatal death or children suffering from birth trauma
COMPLICATIONS 1. Perinatal morbidity and mortality from difficult delivery 2. Low birthweight from preterm delivery, growth restriction, or both 3. Prolapsed cord 4. Placenta previa 5. Fetal, neonatal, and infant anomalies 6. Uterine anomalies and tumors 7. Multiple fetuses 8. Operative intervention, especially cesarean delivery